We gladly reserve appointment times for you. As a courtesy, we will remind you of your appointment by calling and/or text/emailing. However, in the event your mailbox is full, or your line is busy, our efforts to contact you may be unsuccessful. An appointment is a contract of time reserved for your treatment. We respect our patient’s valuable time, and we request the same courtesy from our patients. Please extend this courtesy should you need to cancel and/or reschedule your appointment. We reserve the right to charge $50 for No-Shows and cancelled appointments without advance notice of 48 hours.
As a courtesy, our office will try to direct bill to your insurance (as long as they are set-up with direct billing). In order for us to direct bill, we will require a valid credit card (NOT a visa debit card) to have (securely) on file so that we can charge any remaining amount that your insurance does not cover. If you do not wish to place a credit card on file, you may either pay in full for your treatment and get reimbursed by insurance yourself or pay $100 to have placed as a credit on file.
An attempt will be made to contact you prior to processing any charges on the card. Any amount not paid by your insurance is due within 30 days. We accept Visa, Mastercard, AMEX, Debit and Cash for your convenience.
Ultimately, it is your responsibility to be aware of your dental coverage and also please be aware that some services that we provide may not be covered by your insurance. You are fully responsible for any treatment that is not covered by your insurance plan.
I authorize payment to be made directly to Galaxy Dental by my insurance company, and I accept financial responsibility for all services not covered by my insurance. I authorize the release of any medical care information requested by my insurance company. My signature below acknowledges that I have read and understand this information.