We love referrals! For each adult referral you send to us, we will send you a gift as our way of saying thank you! Refer 3 patients in a year and you will reach VIP status!

*(Does not include referrals of immediate family members. By law, excludes Medicaid)

We require 48 hours notice for appointment cancellations. Appointment changes without adequate notice may be subject to a fee of up to $250.00, payable by the patient and not the insurance company.

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body, Health problems that you may have, or medication that you may be taking.

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, It is my responsibility to inform the dental office of any changes in medical status.

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. 

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.  

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 

The patient understands that:

• Protected health information may be disclosed or used for treatment, payment, or dental/health care operations.
• The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice. 
• The Practice reserves the right to change the Notice of Privacy Practices. 
• The patient has the right to restrict the uses of their information but the Practice does not have to agree to the restrictions. 
• The patient may revoke this Consent in writing at any time and all future disclosures will then cease. 
• The Practice may condition receipt of treatment upon the execution of this Consent. 

Due to the changing world of healthcare and technology, Brighter Smile has the ability to provide our patients with certain types of information viaemail and/or text messaging. If you wish to have the opportunity to receive information of this type, please complete the form below.

Brighter Smile believes strongly in protecting the privacy of our patients. When you provide the information to us, it is only used as a way to communicate with you. In order to protect your privacy, no confidential or personal information will be sent from Brighter Smile via email or text messaging. Brighter Smile does not share the names, e-mail and or telephone numbers of patients with any other company, or with any other patient.

Due to the changing world of healthcare and technology, Brighter Smile has the ability to provide our patients with certain types of information viaemail and/or text messaging. If you wish to have the opportunity to receive information of this type, please complete the form below.

Brighter Smile believes strongly in protecting the privacy of our patients. When you provide the information to us, it is only used as a way to communicate with you. In order to protect your privacy, no confidential or personal information will be sent from Brighter Smile via email or text messaging. Brighter Smile does not share the names, e-mail and or telephone numbers of patients with any other company, or with any other patient.

I hereby give Brighter Smile permission to send messages via email and/or text messaging as a means of communication as indicated by my selection above.

Thank you for choosing Brighter Smile for your health care needs. We are committed to providing the very best dental care treatment. We realize that every person’s financial situation is different. For this reason, we have worked hard to provide a variety of payment options to help you receive the dental care you need and deserve that allows you to enjoy a healthy, beautiful smile with respect to your budget. The following is a statement of our financial policy, which you must read, agree to, and sign prior to treatment. Our Financial Policy applies to all services rendered by our office staff. Dental treatment is an excellent investment in an individual’s medical and psychological care. We are always available to answer your questions or assist you in any way we can.

Practice payment policy:

1. Patients/guardians are financially responsible for all charges, regardless of third party.
2. Full payment is due at the time of service; we will continue to bill your insurance and have reimbursement go directly to you.
3. Patients with insurance will be required to pay all fees at the time of service
4. We accept: Cash, Check, and all Major credit cards.
5. We require a $100 nonrefundable deposit to schedule an appointment that will be applied to your balance at time of checkout for the services rendered at the scheduled appointment.

Patient/Guardian Financial Responsibilities:

1. Patients are expected to pay for the services received in full at the time of service, unless a satisfactory payment agreement has been arranged with our billing manager prior to the services being rendered.
2. We will continue to submit claims and paperwork to your insurance as a courtesy. Please provide accurate information: You have a responsibility to provide accurate and complete information about your mailing address, dental insurance, and other billing information. If any information changes- name, address, phone, insurance coverage, etc – you must inform this practice immediately to avoid possible insurance denials.
3. Patient with Private Insurance
   Our Dentists participate with most major insurance companies as out-of-network providers. We will file claims to your insurance company for payment directly to you. The practice will expect full payment from the patient at the time of service. Any coverage or payment dispute is a matter between the insurance policy holder and the insurance company.

Patient Payment Agreement

I understand that I am financially responsible for all charges regardless of third–party involvement. I agree to pay for services at the time of service and understand that Brighter Smile will submit claims for me as a courtesy, but the patient is reimbursed from the insurance company.

Payment Terms:

1. Full Pay Cash Discount: We offer a 5% accounting courtesy for treatment plans greater than $1000 when your treatment plan co-pay is paid in full (cash) at the time of proposal. We will still file your insurance and payment will go directly to you the patient.
2. Term Loan: By arrangement with Care Credit and Alphaeon we offer our patients, upon approval, an interest-free term loan (3,6, 12, or 24 months) with no down payment, no annual fee, and no prepayment penalty. Please ask for an application.

Once a dental appointment has been made, please keep in mind that this time has been reserved especially for you. We require a full 48-hour notice (business hours) for any appointment changes or cancellations-including failed appointments. We reserve the right to charge $250.00 for appointments without 48 “business” hours including failed appointments. Brighter Smile requires a credit card on file to secure your reserved dental appointment.

By signing this notice of financial and cancellation policy, I am acknowledging that the policy has been read in its entirety.

I also understand that payment of this account is my full responsibility.