Health Update

Patient Information

If there has been a change in dental insurance, please provide your new insurance below

Disclaimer and signature

FINANCIAL POLICIES

Payment for professional services is due at the time dental treatment is provided. If your insurance has copays and/or a deductible, the estimated amount will be collected at the time of service. If you do not have dental insurance, the full amount will be collected at the time of service. Past due accounts are subject to $5.00 monthly billing fees until the account is paid in full. Delinquent accounts are also subject to collection action after four failed attempts to collect the debt. In the event that your family account is submitted to our collection agency, the patient doctor relationship will be terminated. We will transfer any records upon your request.

BROKEN APPOINTMENT POLICIES

A charge of $30.00 is made for hygiene appointments that are missed, cancelled, or rescheduled when less than 24 hours’ notice is given. The charge will be $50.00 for a treatment appointment.

Recare dental visits typically include an exam, cleaning, x-rays, and fluoride treatment. Your signature provides consent for these procedures.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.