Financial Consent Form

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Thank you for choosing our office for your dental healthcare needs. Dr. Steinberg is an unrestricted, out-of-network provide, which allows us to provide a wide array of treatment option using premium materials without the rigid limitations of insurance company policies. Financial arrangements must be made in advance. Patients who carry insurance understand that all dental services are charged directly to the patient and that he/she is personally responsible for full payment. Our office will help prepare the insurance claim forms or assist in making collections from your insurance company and will credit any such collections to the patient’s account.

All emergency services or any services performed without previous written financial arrangements must be paid in full by cash, VISA MasterCard, Discover or CareCredit at the time of service.

For our patients with insurance we conveniently offer two options.

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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