* We invite you to discuss with us any questions regarding our services. The best Dental health services are based on a friendly, mutual understanding between provider and patient.
* Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the financial manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interested charges and any other expenses incurred in collecting your account.
* Dental Insurance is a contract between you and your insurance carrier. It is the responsibility of the patient/guardian to be aware of their plan limitations and waiting periods. We will be happy to file your claim for you. We may provide you with an ESTIMATED co-payment amount at the time services are rendered, however, any unpaid amount by your insurance company will be your responsibility.
* If multiple occasions arise that you fail to give at least a 24-hour notice of cancellation for a scheduled appointment, there will be a fee of no less than $50.00 billed to your account.
* I authorize the staff to perform and necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims.
* I understand the above information and guarantee this form was completed and update correctly to the best of my knowledge and understand that it is my responsibility to inform this office of any changes to the information I have provided.