Form

Financial Policy

Welcome to Pace Dental! Thank you for choosing our office to provide your dental care. We appreciate your trust and look forward to working with you. We value transparency and open communication, please read and sign our financial policy and do not hesitate to let us know if you have any questions.

Cancellations: Because we reserve time in our schedules to dedicate to you or your child, we request 48-hours notice in the event you must cancel a scheduled appointment. Doing so will prevent being charged a $50 missed appointment or late cancellation fee.

Insurance: If you have dental insurance, we will be happy to file your claim on your behalf. Any amount that is not covered by your insurance is your financial responsibility.

Payment: We accept checks, cash, and credit cards (Visa, MC, Discover, and American Express). In addition, Pace Dental offers payment options, such as CareCredit, please see our treatment coordinator for more information. If payment is made with a check, and it is returned, you will be responsible for a $25 returned check fee.

Payment is due at time of service. Additionally, if you have a balance due following an insurance payment from a previous visit, you will be responsible to make a payment for that amount as well.

First Name

Last Name

Date Of Birth

Patient/Legal Guardian Signature

Date