Thank you for choosing our office to provide your dental care. We appreciate your trust and look forward to working with you. To prevent any misunderstanding and to better serve you, we ask that all patients read and sign our FINANCIAL POLICY. If you have any questions, please ask our team member at the front desk. By providing your signature, this indicates that you have read, fully understand, and fully agree to our policies.

PAYMENT: Payment is due at the time services are scheduled. We accept all major credit cards, cash, checks, and third-party financing as forms of payment. If needed, we will gladly assist you in trying to obtain third party financing, including CareCredit. (Our office offers the 6 months no interest plan with CareCredit)

INSURANCE: While we are not contracted with any insurance policies, we can courtesy file to your primary insurance at your request. We will include any information necessary, including x-rays to aid in helping you attain the full insurance benefit due to you. Insurance benefits will be paid as a reimbursement to you directly from your insurance provider.

RETURNED CHECKS: A $50 returned check fee will be assessed to all returned checks and no future checks can be received as payment.

CANCELLATIONS/MISSED APPOINTMENTS: We request 48-hours notice if you are canceling an appointment. After the first canceled or failed appointment (without proper notice), a $50 cancellation fee may be assessed for canceled or failed appointments without 48-hour notice.

FOR OPERATIVE AND SURGICAL APPOINTMENTS CANCELED/MISSED (without proper notice). a fee of 10% of the total case fee will be added to your balance. In addition, if missed or canceled procedure involves an outside anesthesiologist, a fee of 85% of total anesthesia fee will be added to your account balance.

REFUND POLICY: If a refund is issued, Jovan Prosthodontics requires a 2-week notification. We will issue you a refund minus any work completed, any parts/product ordered, and any lab time performed. This includes a fee of $150.00 for your records appointment if one is required for your treatment. If your payment was made via a credit card transaction, a 3.5% transaction fee will be deducted from your total refund due.

We welcome you to our practice and look forward to helping you establish a healthy, beautiful smile. If there is anything we can do to make your visit here more pleasant, please do not hesitate to ask one of our team members.


Please sign electronically below.

Your browser does not support the signature

Click submit and you hereby give consent to sign this document electronically.

Sending data