We are pleased that you chose the practice of Kristine Houck Morris, DDS for your dental care. Our goal is to provide you with the best, most comprehensive care available. An important part of this goal is to make the cost of optimal care as manageable as possible for our patients.
ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED
We proved the following payment options:
Personal Check (a fee will be applied for checks returned for lack of funds)
Credit Cards: Visa, Mastercard, Discover or American Express
If you have dental insurance, we will do our best to help you receive maximum benefits. In order to achieve this goal, we need your assistance and your understanding of our payment policies.
IF YOU HAVE DENTAL INSURANCE Please initial each of the following:
For our patients with NO dental insurance, a discount of 5% will only be applied to fees that are paid in full with cash or check at the time of treatment. There will be no fee discounts for payment with a credit card.
There will be an additional fee of $35.00 for returned checks. After one returned check, payment will be accepted in the form of cash or credit card only.
Charges may be applied to your account for broken appointments, appointment that are not canceled or rescheduled at least 24 hours before the time that you are scheduled for treatment.
Unpaid balances over 90 days may be turned over to a third party collection agency.
DISCLAIMER: 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.