Financial Agreement

To All Our Patients:

Dr. Lyssa Reed and staff wish to thank you for your confidence in allowing us to address your family’s dental needs. We make every effort to offer our patients state of the art techniques and apply all new, practical and positive developments to our dental practice. To keep our professional office on a sound business basis, we seek your help in complying with an office policy that will enable us to offer you the best possible service. The following financial policy is in effect in our office.

• Many dental procedures are accomplished at one visit. Examples include fillings, crowns, extractions and polishing teeth. If you do not have dental insurance, full payment is required the day service is rendered. We accept Cash, MasterCard, Visa, Discover and Care Credit which can offer up to 1 year without interest.
• If you have dental insurance, we require your coinsurance payment the day of service. Your portion will be estimated using the insurance information we have in our office. It is important to remember that in all insurance situations, the patient is ultimately responsible for compensating us for our services.
• A yearly interest rate of 18% (1.5% monthly) will be applied to balances over 30 days.
• We send statements out as a courtesy to all our patients regardless if a patient has pending insurance.

Broken appointments are a disappointment for everyone. They interfere with dental treatment and cause unnecessary scheduling problems. Therefore, we will make every effort to schedule appointments that are most convenient for you. CONSEQUENTLY, WE REQUIRE THAT YOU MAKE EVERY EFFORT NOT TO CHANGE YOUR APPOINTMENT ONCE IT IS MADE FOR YOU. If appointments are missed or changed on short notice, a cancellation charge of $60 for hygiene appointments or $100 per hour of scheduled appointment time with Dr. Reed will be applied. If appointment changes cannot be avoided, we require 48 business hour (Monday- Thursday) notice.

We appreciate your cooperation. If you have any further questions please our office staff members.

I have read, understood and agreed to the aforementioned office policy:

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.