We welcome you to our practice and will be happy to answer any questions that you may have

Payment Options:

This office is a "Fee for Service" practice. All fees are due, in full, at the time services are rendered. For your
convenience, we accept all major credit cards, cash, and personal checks (with proper identification). Outside
financial arrangements can be made to assist you with your budget through Care Credit (ask for details of
which fee plans are available in this office). For any treatment over $1,000, we offer a courtesy savings of 5%
when all fees are paid in full at the beginning of treatment with cash or check (Only).

Dental Insurance:

We are glad to assist you in obtaining the maximum benefit from your dental insurance plan. All services other
than standard, regular hygiene appointments are due in full at the appointment. We file insurance, as a
courtesy, for reimbursement back to patient. We will accept assignment of payment from your insurance
company for hygiene for patients of record with accounts in good standing. Once insurance payment has been
made, any uncovered amount is the patient's responsibility and that amount is due within 15 days of
statement of account. Continued failure by the patient to pay amounts due that insurance did not cover will
result in the loss of that patient's privilege of being allowed to have insurance filed and rendered as payment on
account. Patient will than be required to pay in full for hygiene appointments. Insurance would still be filed as a
courtesy but no longer accepted as payment towards account.

Appointments:

Our appointments are scheduled to respect your time. We reserve a specofic time for your care and we make
every effort to see you at the time of your appointment. We appreciate your promptness and consideration in
not changing your scheduled time. Appointments that are changed, cancelled, or missed without prior
notification of at least 24 hours (minimum), will be considered as a "Broken Appointment". After 2 broken
appointments, the 3rd time will incur $58 non-refundable broken appointment fee. In addition, after the 3rd
failed appointment, a $77 office fee will required in advance to hold any future appointments. The $77 fee
will be applied towards any fees for services rendered at that appointment. Should that appointment be broken
also, that $77 fee will not be refunded and patient will be dismissed from the practice for failure to comply with
office appointment policy.

I have read, understand and agree to adhere to the policies of this dental practice.

Note: Patients with insurance also sign below for your file, Thank you.

I hereby authorize the release of all information from my records to my insurance company. I authorize
payment of all dental payments payable to me to go directly to my dental provider for any services not paid in
full at time of service.