www.aquadentalaustin.com - Financial Policy Form

Thank you for choosing Aqua Dental for providing you with dental care and making us a partner in your oral health. Our goal is to deliver the best and most comprehensive dental care available. An important part of our mission is making the cost of dental care as easy and manageable for our patients as possible.

We accept Cash, Check, Visa, Mastercard and Care Credit.

Financial arrangements are provided on a case-by-case basis and can be discussed in detail when needed. Please let us know if this is something that we can assist you with to make your dental care possible. We are also providers with Wells Fargo (outside financing company), who offer many interest-free payment options.*

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Aqua Dental relies on payments from its patients and insurance companies. Payment is due in full for all appointments unless prior financial arrangements have been discussed and approved. As a courtesy to our patients, Aqua Dental will file your insurance for you and collect only your estimated portion for each visit. Should your insurance pay anything less than what is expected or estimated, you will be responsible for any remaining balance that the insurance does not pay. In some cases, the insurance will mail payment to the subscriber. If your insurance company pays you, we will collect in full for your visit, and you will get reimbursed by your insurance. Please note that our office may not participate with all plans and may not be an “in-network” or a “contracted” provider with your insurance company. Aqua Dental is not obligated to the insurance company’s fees and does not allow the insurance companies to dictate how we care for our patients. *

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Aqua Dental has an obligation to its patients to provide appointments in a timely manner so that their dental needs can be addressed. We ask for our patient's assistance in helping us make it possible to care for other patients. Should you need to cancel or reschedule an appointment, we ask that you provide us a courtesy call at least 48 hours prior to your appointment so that we may offer the appointment to another patient. Failure to provide proper notice may result in broken appointment fees. In addition, we ask our patients to arrive on time to their appointments. Our office is based off of a schedule, and we want to be kind and respectful to our other patients' appointment times. *

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By signing below you agree to Aqua Dental financial policy. We are honored and consider it a privilege that you
have chosen us to care for you. If you have any questions regarding your visits with us please do not hesitate to ask

Patient or Responsible Party Signature *

Patient Name Printed*

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Date*

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FINANCIAL POLICY