1. Insurance
We are committed to helping you maximize your insurance benefits. As a courtesy, we will verify your dental benefits and submit claims on your behalf. However, we cannot guarantee any coverage or payment from your insurance company.
It is the patient's responsibility to provide accurate and up-to-date insurance information.
Insurance estimates provided by this office are not a guarantee of payment.
The patient is responsible for all charges not covered by insurance.
2. Payment Policy
Payment is due at the time of service and We accept:
Cash: Patient's without Insurance—if Treatment is over $600, a 10% discount will be honored if paid in full with cash only.
Credit/Debit Cards (Visa, Mastercard, Discover, etc.)
Third-party financing (e.g., CareCredit) if approved
3. Financial Responsibility
I understand and agree that:
I am financially responsible for all charges for services provided to me or my dependents, including those not paid by my insurance.
Any balance not paid within 30 days of billing may incur late fees or interest.
Accounts over 90 days past due may be referred to collections.
4. Missed Appointments & Cancellations
We require at least 24 hours' notice for cancellation or rescheduling of appointments.
A $25 fee will be charged for missed hygiene appointments without 24 hours' notice.
For missed Doctor appointments, a fee will apply based on the length of the scheduled visit. Please contact us for specific rates.
NO-CALL/NO-SHOW POLICY: Three (3) no-call/no-show appointments will result in dismissal from the practice.
5. Treatment Estimates
I understand that treatment plans are only estimates and may change based on actual treatment performed or findings during treatment.
6. Refunds
Refunds for overpayments will be issued upon request or automatically applied to future balances unless otherwise specified.
7. Consent & Agreement
