Online Patient Form

Financial Policy

*Patient Name :

Last name

Mid name

First name

We are committed to providing you with the best possible care. If you have dental insurance, we wish to help you receive your maximum allowable benefits. To achieve this, we need your understanding of and assistance with our financial and payment policy.

Payment is required at the time of service. We accept cash, check, or credit card (Visa or MasterCard).

For patient with no insurance, full payment is required at the time of service.

We require co-payments or your liability to be paid at the time of service.

While the filing of insurance claims is a courtesy that we extend to our patients, all charges not covered by your insurance company are your responsibility. We are not a party to your insurance company's contract. Your policy is your responsibility.

Bills unpaid for more than 120 days may be turned over to collection agency unless other arrangements have been made. Accounts that are turned over to collections may result in dismissal from the practice. If the account is turned over to the collection agency, the account will be charged an additional 33% of the total amount owed. Carrying charges will apply after 90 days of unpaid bills.

If special circumstances make immediate payment impossible, payment arrangements must be approved in advance by our business office staff.

Missed appointments: Unless canceled at least 24 hours in advance, there will be a charge of a minimum of $50.00 for missed appointments. Please help us serve you better by keeping scheduled appointments. Multiple missed appointments may result in dismissal from the practice.

* I have read the above Financial Policy and agree to the terms.

*Signature :		Date :
(Your digital signature (full name) is as legally binding as a physical signature.)