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 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. 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. 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. 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.