I understand that dental services furnished to me are charged directly to me and that I am personally responsible for payment. I understand dental insurance is an agreement between me and my dental insurance company. Submitting claims for payment to the insurance provider is a courtesy provided by the dentist. Ultimately, I am responsible for any treatment that is unpaid by the insurance provider.

Estimates and treatment plans are based upon information gained from the examination. The office will make an effort to anticipate any unforeseen changes in the treatment plan and advise me at that time. This is a preliminary estimate only and lab charges (if applicable) have been estimated and included in the total.

If requested, a submission to my insurance provider can predetermine an approximate final investment. Predeterminations from my insurance provider(s) are an estimate only and are NOT a guarantee of payment. (Estimates do not take into consideration any money that was paid toward my financial maximum, or treatment limits to other dental providers.)

I agree to be responsible for all costs of collection on unpaid balances including, but not limited to, 1.5% interest (18% annually), collection fees (up to 50%), court costs and reasonable attorney fees. A returned check fee may also be applied for each check payment returned by my bank.

I hereby authorize FPE DENTAL to charge the authozied amount, as listed above, to my credit card provided. Separate Terms and Conditions may apply with the card issuer agreement. I have read, understand and agree to the office financial policy for payment of professional fees. I understand that I am ultimately responsible for all fees for services rendered to me and/or my family.