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Financial Policy Form

Financial Agreement

Our goal is to provide the highest quality of dental care and have clear communication of our financial agreement.

Please read and initial each section confirming that you understand and agree to our guidelines. A printed copy of this agreement will be given to each responsible party upon request.

Cancellations and Rescheduling

Our practice is dedicated to delivering quality care and exceptional service. Our doctors and team spend extensive amounts of time preparing for your visit. Broken and missed appointments create scheduling problems for our dental team as well as for other patients. If you find that you must make changes to your appointment, we require a minimum of 48 business hours, Monday-Friday (notify us on a Thursday if your appointment is on a Monday) so that we can make every effort to accommodate other patients. If proper notice is not received, a cancellation fee will be charged.

Insurance Coverage

Please remember that your insurance policy is a contract between you and your insurance company; we are not a party to that contract. As a courtesy to you, we verify your eligibility for coverage prior your visit and provide you with treatment estimates to the best of our ability with the limited information provided to us by your insurance. Please be aware that it is physically impossible for us to have knowledge and keep track of every aspect of your insurance. It is up to you to contact your insurance company and inquire as to what benefits you or your employer has purchased for you. If you have any questions concerning these estimates and/or fees for services, it is your responsibility to have them answered prior to treatment to minimize any confusion on your behalf. Please be aware that some services provided may or may not be covered by your insurance policy. Any balance is your responsibility whether or not your insurance company pays any portion. If your insurance does not process payment for our services within the 90 days allotted after they are rendered, you are responsible for paying any unpaid amounts: the statement will be in your name. For patients with or without insurance, payment in the form of cash, credit card, check, or Care Credit are to be made at the time your appointment is reserved unless prior arrangements are made.

Bounced Checks

In the event of bounced checks for services rendered, the patient will be responsible for any bank and office surcharges arising from the incident.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.