Consent for Treatment:
I hereby authorize the dentist or designated staff to take radiographs, study models, photographs and other diagnotic aids deemed appropriate by the dentist to make a thorough diagnosis as mutually agree upon by me.
I agree to be responsible for payment of all services rendered on my behalf and/or on behalf of my dependants. I understand that payment is due at anytime of service unless other arrangements have been made.
Payment for Treatment:
We accept cash, Visa, MasterCard, Discover, American Express and Care Credit.
Care Credit is a private payment program we offer. For additional information please ask one of our representatives at the front desk.
Our fees, when quoted for treatment, will be honored for 90 days. Beyond that, fees may be adjusted to reflect any cost increases.
Should the account become past due and be referred to a collection agency, the undersigned agrees to pay any and all additional costs/fees and/or interest charged by, or as a result of the referral, to a collection agency, In addition, should the account be referred to an attorney for collections, the undersigned agrees to pay any and all attorney’s costs/fees and/or interested charged as a result of the referral.
Most insurance plans do not cover 100% of your cost of treatment. Therefore, you will be expected to pay your deductible and your ESTIMATED co-payment on the day services are rendered. Many variables exist from carrier to carrier (ex: deductibles, annual maximums, allowable fee limitations, non-covered procedures and other restrictions), therefore, we cannot guarantee any estimated charges.
You are responsible for advising our office if you have a change in your insurance coverage prior to your appointment. Your insurance is an agreement between you and the insurance company, ultimately you are responsible for all charges. If for some reason your insurance company has not paid their estimated portion within 60 days from the start of treatment, you are responsible for payment in full at that time. Treatment could be altered if your dental needs change. The patient will be notified of any change(s) in treatment. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. If your insurance company deems a procedure as not a covered benefit patient is responsible for full payment.
Patients are seen by reservation, emergencies and walk-ins will be seen as time permits. We respectfully ask that you give us 48 hour notice (2 business days) to reschedule your reservation. If you fail to do so, you will be subject to a $75.00 failed/less than 48 hour notice cancellation reservation fee.
I understand the consent for treatment and policies as stated above.
By my electronic signature below, I agree to the terms and conditions.
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health and I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form. It is my responsibility to inform the dental office of any changes in medical status.