Financial Agreement
Thank you for choosing our office for your dental needs. Dental treatment is an excellent investment in an
individual's overall health and quality of life. Financial considerations should not be an obstacle to obtaining
this important care. To assist you in choosing the method of payment that is best for your situation, we have
several financing options available.
Unless financial arrangements are made in advance, fees are due and payable at the time treatment is rendered. We
accept cash, personal checks, credit and debit cards (Visa, Discover, MasterCard) and CareCredit.
Please note that overdue balances are subject to $35 late fee or 3% of the past due amount, whichever is
greater.
For our patients with dental insurance: We are happy to assist you in filing the necessary
forms to help you receive the full benefits of your coverage. Payment for your estimated portion is due and payable
at time of service. The insurance relationship constitutes an agreement between the carrier and the patient. As
such, we can make no guarantee of estimated coverage or payment. Since we cannot guarantee your exact insurance
coverage, there may be a balance remaining after insurance payment is received. We ask that you pay this balance
upon receipt of invoice.
I understand that any insurance estimate given to me by this office is not a guarantee of actual insurance payment.
I also understand that I am ultimately responsible for all charges incurred for dentistry performed upon myself or
my dependents. Any insurance claim not paid in full will become my responsibility to pay.
Reservation Agreement
As our patient, and to ensure we deliver exceptional dental care, we want to assure that we are 100% committed to
providing timely and quality service to all our patients. We believe an equally important aspect of delivering
exceptional dental care is our patients' commitment to our practice as well. Therefore, we request you honor your
scheduled appointment as a "reservation" as we reserve that time specifically and only for you.
Should you have to change your reservation for any reason, we request you give our practice a minimum of 48 hours (2
business days) notice within the hours of 9am-2pm.
Missed appointments increase the cost of healthcare for everyone. Therefore, if a reserved
appointment is missed or changed without 48 hours' notice you may be required to pay a $25.00 reservation fee in
order to reserve your next appointment. The reservation fee will then be applied to treatment rendered, or forfeited
if your reserved appointment is missed or canceled without the required 48 hours' notice.
Deposit Policy. Due to the extensive amount of time our staff and doctor devote to preparing
and reserving time for your treatment, we require a 20% non-refundable deposit for all treatment costing
$300.00 and above. This deposit fee will be applied toward the scheduled treatment. In the event your
reserved appointment is missed or canceled without the required 48 hours' notice, the deposit fee will be forfeited.
Thank you! We appreciate your understanding in this matter.
