As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment.
All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash or credit card at the time services are performed unless other arrangements have been made.
Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will prepare the patient’s insurance forms or assist in making collections from the insurance companies and will credit any collections to the patient’s account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.
I understand that any treatment plan fee estimates for this dental care can only be extended for a period of three months from the date of the patient examination.
In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment. I further agree that the charges for services shall be billed at the time treatment is rendered. In the event I default on my payments, I am responsible for court costs, collection costs and attorney’s fees.
I grant my permission to you and your assignee, to telephone me to discuss that statement or my treatment.
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