Financial Policy Form

Our office makes every effort to hold down the cost of your dental care. You can help us by paying upon completion of each dental visit. You may pay for your visit by:

CASH, PERSONAL CHECK, CREDIT CARD (VISA, MASTERCARD OR DISCOVER)

DENTAL INSURANCE POLICY

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some insurance plans will pay a fixed allowance for certain procedures and others pay a percentage of the allowed charge. It is the patient's responsibility to pay the deductible amount, co-insurance, or any other balance not paid for by your insurance company.

If the patient's insurance company required a “pre-treatment” will provide this service at no charge.

We know questions can arise on insurance matters and these should be discussed with our office personnel. We will be happy to help you receive maximum benefits; however, the agreement of the insurance company to pay for dental care is a contract between you and your company.

FINANCING YOUR DENTISTRY

For those patients who require financing for their dentistry, we offer the ability to spread the cost of your dental work over 2 to 6 months. We charge a 1% finance charge on the unpaid monthly balance over 59 days old. In all cases requiring lab work such as crowns, bridges, or dentures, we require at least a 50% down payment. Patients may make the financing arrangements with our office staff. A financial contract will be given to the patient with the details of the financing arrangement. In the event of default, the patient agrees to pay all costs incurred to collect for services rendered, including but not limited to reasonable attorney fees and court costs.

| have read and understand the financial policy and agree to its terms.

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.