WE ARE COMMITTED TO YOUR DENTAL CARE BEING SUCCESSFUL. PLEASE UDNERSTAND THAT PAYMENT FOR YOUR CARE IS CONSIDERED PART OF THAT CARE. PLEASE READ THE FOLLOWING INFORMATIONC AREFULLY. WE ASK THAT YOU READ AGREE TO AND SIGN PRIOR TO ANY TREATMENT
– ALL PATIENTS MUST COMPLETE OUR PATIENT INFORMATION FORM BEFORE RECEIVING TREATMENT
– FULL PAYMENT IS DUE AT THE TIME OF SERVICE UNLESS PREVIOUS ARRANGEMENTS HAVE BEEN MADE
– PATIENTS WHO CARRY DENTAL INSURANCE UNDERSTAND THAT ALL DENTAL SERVICES FURNISHED ARE CHARGED DIRECTY TO THE PATIENT’S ACCOUNT. WE WILL COMPLETE THE PATIENTS INSURANCE FORMS OR ASSIST IN MAKING COLLECTION FROM INSURANCE COMPANIES AND WILL CREDIT ANY SUCH COLLECTIONS TO THE PATIENT’S ACCOUNT. HOWEVER THIS DENTAL OFFICE CANNOT RENDER SERVICES ON THE ASSUMPTION THAT OUR CHARGES WILL BE PAID BY AN INSURANCE COMPANY
– ESTIMATED CO-PAY AND DEDUCTIBLE IS DUE AT THE TIME OF SERVICE
– WE ACCEPT CASH, VISA, MASTERCARD AND DEBIT
– THERE WILL BE A CHARGE FOR APPOINTMENTS MISSED WITHOUT 2 BUSINESS DAYS NOTICE
PLEASE LET US KNOW IF YOU HAVE ANY QUESTIONS OR CONCERNS REGARDING THIS INFORMATION.
I HAVE READ THE ABOVE CONDITIONS OF TREATMENT AND PAYMENT AND AGREE TO THEIR CONTENT.