Office Policy Form

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Thank you for choosing us as your dental care provider. We are committed to providing you the highest quality dental care, utilizing the best materials and education available. The following is a statement of our Office Policy, which we require you read and sign prior to any treatment.

All patients must complete our Patient Registration and History form before seeing the doctor.

PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED. Our office accepts cash, personal checks, Discover, MasterCard, Visa, and American Express. We also offer Care Credit as a financing option. We can even apply for you here in the office and give you an instant answer!

Returned checks and balances older than 60 days are subject to collection fees and interest charges.

Minor Patients

The parent, guardian, or adult accompanying a minor is responsible for full payment at time of visit. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved form of payment at the times of services has been verified.

Regarding Insurance

Your insurance policy is a contract between you and your insurance company. We are not a party in that contract. All incurred charges are ultimately the responsibility of the patient regardless of insurance coverage. In the event your insurance doesn’t pay for a procedure, you are responsible for any remaining balance.

Appointment Policy

It is our policy for you to give us 48 hours’ notice if you need to change an appointment, and for you call and speak directly with a staff member as our answering machine does not accept changes or cancellations. We will not charge for your first missed appointment. However, if you miss an appointment a second time we will reschedule when you pre-pay for the treatment in full. If you keep the appointment, the payment will be applied towards treatment. However, if you fail to keep the appointment a second time, the payment will be applied towards lost production time.

Thank you for understanding our Office Policy. Please let us know if you have any questions or concerns. We are committed to proving the most positive experience in dental care.

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

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