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Financial Agreement Form

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.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.