I request and authorize Dr. Mosley to examine, clean, and provide dental treatment on my child’s teeth. I further request and authorize the taking of dental x-rays as may be considered necessary by Dr. Mosley to diagnose and/or treat my child’s dental problem. I will allow photographs to be taken of my child or child’s teeth for diagnostic or educational purposes. I understand that dental treatment for children includes efforts to guide their behavior by helping them to understand the treatment in terms appropriate for their age. Dr. Mosley will provide an environment likely to help children learn to cooperate during treatment by using praise, explanation and demonstration of procedures and instruments, and using variable voice tone. I will be responsible for any charges incurred on this child for dental treatment.
Thank you for choosing Danville Pediatric Dentistry for your child’s dental care.Please read our financial agreement. Sign and date prior to any treatment.
For my convenience, this office may release my information to my insurance company, and receive payment directly from them.
I will pay a $25 fee for appointments broken without 24 hour notice.
Treatment plans sometimes change, and I will be responsible for the work completed on the date of service.
In an effort to make our patients' dental care affordable, payment is required at the time of treatment. If you do not have dental insurance, full payment is due at the time of service. If you have dental insurance, we require an estimated co-payment on the date services are rendered. If your account has an overdue balance, future treatment may be delayed until your balance has been paid in full. For your convenience, we accept cash, check, CareCredit or credit. We do not offer payment plans.
I understand that fees for services not covered by my insurance are my financial responsibility. Any insurance quote received from Danville Pediatric Dentistry is only an estimate of your dental benefits and not a guarantee of payment. If your insurance is ineligible on the date of service, you are responsible for all payments. As the insured, it is your responsibility for the understanding of your policy.
PLEASE KEEP IN MIND OUR FINANCIAL POLICY APPLIES TO WHOEVER BRINGS THE CHILD IN FOR TREATMENT. THAT PERSON IS FINANCIALLY RESPONSIBLE FOR ANY CHARGES INCURRED ON THE DAY OF THE APPOINTMENT. WE DO NOT SEND STATEMENTS TO OTHERS OR OTHER PARENTS.
Please note that Danville Pediatric Dentistry is in network with Delta Dental and VA and NC Medicaid. We will file all other insurances as a courtesy to our patients but the balance due will be the responsibility of the legal guardian.
I have read, understand, and agree to the Danville Pediatric Dentistry financial agreement.