Thank you for choosing our practice as your healthcare provider. In our continued commitment to provide you and your family with quality dental care, we are asking that you pay at the time of treatment. Therefore, any other financial arrangements must be approved in advance.

If you have dental insurance, we will be happy to bill them for you. We will estimate what your out-of-pocket portion will be and collect the patient portion (including any deductible) at the time of treatment. We accept checks, Mastercard, Visa, Discover, American Express and Care Credit. Please ask us if you need any more details or other options.

As a courtesy, we will gladly bill your dental insurance and do our best in preparing your insurance forms or assist in collecting benefits from insurance companies. However, our dental practice cannot guarantee any payments or benefits from any outside sources. If a claim is not paid within 60 days, the balance is your responsibility and we ask for you to pay the remaining balance. To assist in billing your claim, please come to your appointment with all necessary DENTAL insurance information. We encourage you to contact your insurance prior to treatment. 

Our office does our best to provide optimal care for every patient. The Proposed Treatment Plan fee estimate listed is just that, an estimate. Treatment Plans developed in this practice are subject to change depending on the specific dental condition.

 

If for any reason you request records or x-ray transfer, an administrative fee may be charged.
Returned check fee is $35.00
Proposed Treatment Plan fees quoted are honored for (3) months
I grant permission to you and your team, to telephone me at any time to discuss matters related in this form.
I have read and fully understand the above conditions of treatment and agree to its content.
Accounts over 60 days from treatment will bear interest of 1.8% monthly and are subject to be sent to an outside collection agency.