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Financial Policy

Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.

Patient Name

Date Of Birth

Payment Options:
We accept payment in the following forms:

o Cash, Visa, MasterCard, or Discover- WE DO NOT ACCEPT CHECKS
o Convenient Monthly Payment Plans¹ from CareCredit

Payment Scheduling:
Sparks Dentistry requires payment at the time of treatment. Our office does our best to calculate your patient liability based on the information provided for us by your insurance carrier. In some instances, the insurance company may pay more or less than expected based on the information that they provided, and you may be responsible for the difference. Your insurance policy is a contract between you and your insurance carrier, and any questions regarding your coverage or patient liability should be directed to them. Please also be aware that we recommend and provide treatment based on patient need, not based on insurance coverage, and that you will be responsible for any treatment or procedure that you consent to if it is not covered by your insurance policy.

For procedures requiring multiple appointments, arrangements may be made to pay half at the first appointment, with the remainder due prior to the completion of your treatment. If you choose to discontinue care before treatment is complete, your refund will be determined upon review of your case.

For large balances or procedures with large patient liabilities, Sparks Dentistry may offer payment plans. Please ask at the Front Desk for more information.

Cancellations:
Once an appointment is made, please remember this time has been reserved for you. All reminder calls and communications are done as a courtesy and you are responsible for keeping appointments that you have made. Below are the charges that will be made for repeated failed or cancelled appointments without prior notification of 24 hours.

· A fee of $45 is charged for patients who miss or cancel cleaning appointment without 24 hour notice.
· A fee of $100 per hour is charged for patients who miss or cancel any other type of appointment (filling, crowns, denture, root canal, etc.) without 24 hour notice

All balances, including for cancelled appointments, must be settled prior to rescheduling a cancelled appointment.

We send statements to any patients with balances monthly. If balance is not settled in full following three statements, Sparks Dentistry reserves the right to send the account to a third-party service for collections, and/or dismiss the patient from the practice.

Patient or Legal Guardian Signature

Date