Financial Policy
As validated by my signature on the bottom of this form, I understand and agree that: 
All payments are due the same day treatment is rendered. Please ask us if you are interested in learning about third party financing, which may allow you to finance your treatment in low monthly payments.

A returned check fee may also be applied 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 the dentist, not an obligation. Ultimately, I am responsible for any treatment that is unpaid by the insurance provider. I also understand that the given insurance reimbursement estimate from our office is solely an estimate. We are not responsible if an insurance company reimburses a different estimate than what was quoted at our office.

If there is dental insurance on the account, I understand that the clinic has established the patient charges based on the information I have provided. Final treatment insurance reimbursement is subject to the terms and conditions of my insurance provider on the date of service. 

Estimates and treatment plans are based upon information gained from the examination. As with any dental treatment, there may be unforeseen treatment adjustments and/or complications. This is a preliminary estimate only and lab charges (if applicable) have been estimated and included total. 

Estimates do not take into consideration any money that was billed toward my financial maximum or treatment limits that may have been used at other dental clinics. 

A submission to my insurance provider will be sent to determine an approximate final investment. However, it is an estimate only. Final insurance splits may be adjusted upon receiving the predeterminations. Predeterminations from my insurance provider(s) are NOT a guarantee of payment. 

As with any dental treatment, there may be unforeseen treatment adjustments and/or complications. The clinic will make an effort to anticipate any changes in the treatment plan and advise me at that time. However, such events are unpredictable. Likewise, the timing or spacing of appointments may need to be modified as needed to accomplish the best result possible. 

The clinic will make every effort to accommodate my scheduling needs. 

I have read, understand and agree to the above 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.