As validated by your signature on the bottom of this form, you understand and agree that:
Payment is due at time of service. If the financially responsible person is not present at the appointment, payment will be due prior to the appointment.
A cancelation fee of $99 may be charged for patients who miss or cancel an appointment without 24 hour notice. If a patient cacels three appointments, the patient may be dismissed from our practice and asked to find another dentist.
A returned check fee of $50 will be applied to your account and must be payable from you for each check payment returned to us by your bank.
Dental Insurance: By signing below, I authorize Smiles by Delivery to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim. It is my responsibility to verify whether my insurance is an out-of-network or in-network plan and if my insurance is active. I understand that Smiles by Delivery can assist me in verifying this information.
PPO Out-of-Network Plans: Dental insurance is a contract between the patient, their employer (if applicable) and the insurance provider. Submitting claims for payment to the insurance provider is a courtesy provided by Smiles by Delivery, not an obligation. I understand that if Smiles by Delivery is out-of-network with my dental insurance plan, my insurance is not accepted as a form of payment.
In-Network Plans: If Smiles by Delivery is in network with my dental insurance, I authorize my insurance benefit to be directed to Smiles by Delivery. Ultimately, I am responsible for any treatment that is unpaid by the insurance provider.
*By signing below, I consent to any recommended x-rays, teledentistry exams, clinical exams, cleanings (prophy or fullmouth debridement), and fluoride treatments. I understand that a licensed dental hygienist or licensed affiliated practice dental hygienist will be providing the dental hygiene services. Dental hygiene care alone does not take the place of a dental examination or complete dental care. The teledentistry exams, clinical exams, dental diagnosis, treatment plans and restorative treatments are provided by licensed dentists, which may follow the appointment with the hygienist.