Financial Policy Form

To Our Valued Patient

Please be advised, our patients are responsible to pay for treatment at the time the service is rendered, including patients with co-pay of their dental insurance. When applicable, you will be reimbursed by your insurance directly.

• DENTAL INSURANCE is a CONTRACT between your employer and insurance company. All insurance inquiries are to be done by the patient and/or insured.
• Benefit coverage is a contract between yourself, the insurance company, and your employer, NOT the dentist.
• A 50% payment is required for all major treatments upon reservation of the appointment. The balance of the total fee agreed upon is to be paid upon completion of the treatment unless written financial arrangements have been made in advance with our front staff.
• Appointments missed or short notice cancellations without 48-hour notice will result in a $75 charge.
• For your convenience, we accept the following forms of payment: cash, debit, direct deposit (e-transfer), Visa and Mastercard.

As a courtesy, our clinic will assist in filing your dental claims to the dental insurance. Payments from the insurance company will be directed to the patient/insured, when applicable.

If you have any questions or concerns, please feel free to reach out to any of our front staff. We thank you for your cooperation.

I have read and understood the above policies and agree to them

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.