All insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

DENTAL HISTORY

If you have had any x-rays taken in the last 5 years, it is the patient's responsibility to have them emailed to karavolasdentistry@gmail.com before your initial visit.

For Women

MEDICATIONS

ALLERGIES

SIGNATURE

The above information is accurate and complete to the best of my knowledge. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

 

As your dental provider, we are committed to providing you with the best possible dental care. In order to achieve this goal, we need your assistance and understanding of our policies.

PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED. We accept cash, checks, Visa, Mastercard, Discover, American Express, and Care Credit.

FINANCIAL AGREEMENT/INSURANCE COVERAGE: As a courtesy, we will bill your insurance on your behalf. We will gladly discuss your proposed treatment and do our best to answer any questions relating to your insurance. However, you must realize that:

• Your insurance is a contract between you and the insurance company. Our office is not responsible for benefits not paid by your insurance company.
• Our office ESTIMATES your portion. This is only an estimate. For a more exact estimate, you may request that we submit for a written pre-determination prior to the start of our treatment. Please note that this can be a lengthy process and may take several weeks before the pre-determination is processed by your insurance company.
• Not all services are covered benefits under all contracts. Some insurance plans exclude coverage of certain services or downgrade services to a less-expensive service than the service we provide without prior notice.
• All charges are your responsibility from the date services are rendered. You may need to contact your insurance company if there are any questions regarding the company’s handling of a claim.

We must emphasize that as your dental care provider, our relationship is with you and your dental health, not the insurance company.

MISSED, CANCELLED, AND RESCHEDULED APPOINTMENTS: As a courtesy, we make multiple attempts to confirm appointments by email, text, and phone. Unconfirmed appointments are cancelled by the office if confirmation is not received by the deadline. We ask that you give us an advanced notice of 24 hours when cancelling or rescheduling an appointment by calling or emailing the office. It is okay to leave a message with our answering service if you call outside of normal business hours. Of course, reasonable consideration will always be given to extenuating circumstances, such as unforeseen emergencies. OUR FEE FOR MISSED, CANCELLED, OR RESCHEDULED APPOINTMENTS WITHOUT 24 HOURS NOTICE (In the absence of any extenuating circumstance) is $75. Certain longer appointments may require a larger cancellation fee and/or a deposit to re-schedule the appointment.

If you have any questions about the information or any uncertainty regarding our policies, please do not hesitate to ask us. We are here to help you.

I have read and understand these policies.