Appointment & Financial Standard of Care

Thank you for choosing Park View Family Dentistry. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options. We are committed to providing excellent dental treatment to all of our patients. Our fees reflect our team's level of expertise and the quality of care we deliver.

Appointment Confirmation

Appointment time has been reserved for your specific treatment. All appointments are to be confirmed at least 24 hours prior to scheduled appointment time. Incidences of failure to provide at least 24-hour notice if you are unable to keep your appointment will be managed by the following policy:

• First late cancel or no-show: your chart is noted and you a reminded of the policy verbally
• Second late cancel or no-show: you will receive a Warning Letter reiterating our policy and a $65 late cancel fee will be applied to your ledger
• A third late cancel or no-show will result in dismissal from the practice

Payment Options

We offer several payment options for your convenience:

• We accept Cash, Check, Visa, MasterCard, and Discover
• We offer convenient monthly payment options from Care Credit Healthcare Credit Card
• There is a $25 fee for returned checks

Insurance

Our office is committed to helping our patient maximize their benefits. Dental insurance is becoming extremely complex. We are always available to answer your questions. Nevertheless, your insurance policy is an agreement between you and your insurance company. As a dental provider, we are not party to that agreement. As a courtesy, we are happy to submit to and work with your carrier to maximize your benefit. Any insurance information is strictly an estimate. We will attempt to verify eligibility before your appointment, but this is not a guarantee of payment from your insurance company.

Financial Consent

The patient (account holder) agrees to be fully responsible for total payment of treatment performed in this office. I understand and agree to this Financial Policy and Agreement. Furthermore, I authorize release of any information relating to this claim or any insurance information. I understand that I am responsible for all dental treatment not covered by my insurance.

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