In our continued commitment to provide the highest quality dental care available to all of our patients and to have those services comfortably affordable, we are pleased to offer you these options for payments.

• We are committed to support you in understanding your dental health, so that you will always be able to make the best choices.
• We will, as a courtesy, process your insurance benefits in our office, which will relieve you of this time consuming and sometime complicated task.

I agree that I am fully responsible for the total payment of all procedures performed in this office –this includes any treatment that is not a covered benefit of any dental insurance that I may have. I understand that all services are due to be paid in full within sixty (60) days of the date of service, regardless of whether or not my insurance benefits have been received. One and one-half percent( 1.5%) per month interest (18% per year ) will be charged on accounts 60 days from treatment date.

MISSED APPOINTMENTS

Appointment times are reserved especially for you and it is bond of trust between you and our office. In helping us serve you better please keep your scheduled appointments. Our time is dedicated to high quality services at reasonable cost and in order to deliver this we ask that you choose a time that you will be committed to, it is important that you notify us at least 48 hours before your appointment if you need to cancel or reschedule. We reserve the right to charge a $35.00 missed appointment fee for broken/missed appointments. We are here to assist you in any way possible. Please make your questions and concerns known to our team. Our goal is to ensure that you have an outstanding experience.

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	Office Financial Policy Form		(24.0 KB)
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