By signing below, I hereby certify that to the best of my knowledge all the information I have furnished on this form is complete, true and accurate.

Whom may we thank for referring you to our practice? Name of person or office referring you to our practice:

By signing below, I hereby certify that to the best of my knowledge all the information I have furnished on this form is complete, true and accurate.

You are fortunate to have dental insurance, whether you have purchased it or your employer has provided it for you. Though your dental insurance is your responsibility we can help! We will go the extra mile to help you maximize your benefits. As a courtesy, we will help by filing your insurance forms, which will save you considerable time and trouble. We accept payments from most insurance companies, which reduces your immediate out-of-pocket expense. Insurance is a method of payment not a method of treatment. Regardless of what we may calculate your insurance company to pay, it is only an estimate. Our estimate is based on limited information obtained from your insurance company. You must understand, we cannot forecast what they will pay.

We must stress that you are responsible for the total treatment fee. Your dental insurance is not designed to pay the entire cost of your treatment, but it is intended to help cover a certain portion of the cost. A better term for dental insurance may be "dental assistance".

Please remember, however, the financial obligation for dental treatment is between you and your insurance company, and is not between this office and your insurance company.

It often takes us a considerable amount of time to try to collect your insurance payment for you. We often need your help to discuss your situation directly with your insurance. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient, and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, we cannot render services on the assumption that our charges will be paid by an insurance company. In addition, this form also authorizes this practice to submit insurance claim forms and receive payments directly from the Insurance carrier with the notation “SIGNATURE ON FILE”. 

If an account is outstanding for more than sixty (60) days, a monthly service charge of 1.5% may be added to the balance. If the account is not cleared within the time specified, the account will be turned over to our collection service with additional charge of $35 towards the pending balance and a report may be filed with a credit servicing agency, such as Equifax. Insurance co-payments and deductibles are due at the time of service by payment method of cash or credit card. WE DO NOT ACCEPT PERSONAL CHECKS.

Information about my invoice or accounts payable upon request, to patient/legal guardian

Information about a specific dental visit

Digital x-rays, referrals and/or orders to a dental specialist about treatment

I have read and understand the above and acknowledge that I have been given or offered a copy of the offices “Notice of Privacy Practices”.

1. Full pay cash discount: We offer a 5% accounting courtesy for all services over $500 that is paid in full prior to the start of treatment. 3% discount for using your credit card.
   
   
2. In Office Term: 50% of full service fee at the beginning of treatment and remaining 50% before completion of treatment. By making monthly payments with interest of 5%. Cash or Credit Card Only
   
   
3. Term Loan: By arrangements with CARECREDIT we can offer patients upon approval, an interest-free term loan (up to 6-18 months) with no down payment, no annual fee and no prepayment penalty. Ask for an application.

Your time is as valuable as ours. We make every effort to see you at your reserved time. We apologize in advance if you are not seen exactly at your scheduled time; please understand that we do try to work- in dental emergencies.

As a courtesy we attempt to confirm each scheduled appointment, however, as the patient you are responsible to keep up with your reserved time and are still subject to the cancellation/ broken appointment fee of $45 per half hour, not to exceed $150 for lengthier appointments, should you not make it to your appointment. INSURANCE COMPANIES DO NOT PAY YOUR BROKEN APPOINTMENT FEES. Please inform us if any address or contact information needs to be updated. The office must be notified within 48 business hour if you wish to make any changes to your scheduled appointment.

A $35 deposit required for all restorative procedures. A $150 deposit is required for all procedures resrved for 90 minutes or more. This amount will be applied to your out-of-pocket expenses not covered by your insurance. Should you miss your appointment without cancellation 48 hours before; your deposit will be forfeited.

At Modern Smile Dental, we understand how difficult it can be for patients and their families to find time for scheduling dental appointments. After-school activities, sports teams, work, family, and social obligations all require time from packed schedules. Our flexible scheduling is part of our dedication to serving our patients and their families. We want you to get the best dental care you need, when you need it. We understand that illness, emergencies, flat tires, and bad weather do occur. We ask our patients to give us 48 hours’ notice whenever possible, if they cannot keep an appointment. This allows us time to fill our schedule with other patients who may be waiting.

• No privilege of a Saturday appointment for future appointments, until 3 consecutive completed appointments
  
  

Definition of “Broken Appointment”: A broken appointment is when you

• Cancel or reschedule an appointment with less than 48 hours notice
  
  
• Do not show up for the scheduled appointment
  
  

I have reviewed, understand, and agree to comply with the above office policies.