In an effort to keep dental costs down while maintaining a high level of professional care, we have established the following payment plans for use by our patients. We encourage our patients to discuss any questions they may have regarding our policies.

1. Payment in full at time of visit is due unless prior financial arrangements have been made.
2. Payment may be made by cash, check or charge.

All major treatments require an appropriate down payment. To avoid misunderstandings,
our office manager will be happy to discuss any questions and/or financial concerns
regarding fees and payments.

An itemized statement covering all services received will be mailed on a monthly basis and will reflect the amount currently out on insurance.

If you have dental insurance, we will be happy to help you determine the coverage you have available. Your insurance policy, however, is a contract between you and your insurance company. We, therefore, cannot guarantee payment of your claims or accept the responsibility of negotiating claims with insurance companies or other persons. If your insurance company pays only a portion of the bill or rejects your claim, you are responsible for full payment for services rendered.

I hereby authorize the release of any dental information necessary to process insurance claims. I authorize the payment of benefits to the dentist described herein for services rendered. I also have read the above section on insurance and agree to its terms.