Thank you for choosing our office to provide your dental care. We truly appreciate your trust and look forward to working with you. In order to prevent any misunderstanding and to better serve you, we ask that all patients read and sign our financial agreement. If you have any questions, please speak with our front office staff. By providing your signature, this indicates that you have read, fully understand, and fully agree to our practice policies.

PAYMENT: Payment is due in full at the time of the service. We accept all major credit cards, checks, Third Party Patient Financing, and/or cash as forms of payment.

Third Party Payment: While our practice does not offer in house financing, we do work with Care Credit and Green Sky as third-party patient financing. Both companies offer convenient monthly payment options and no up-front out of pocket. They both offer 6 months repayment with no additional interest and also offer longer repayment options that do include interest based on credit.

INSURANCE: While we are not contracted with any insurance policies, we can courtesy file to your primary insurance at your request. Any insurance benefits paid are to be considered a reimbursement to you directly from your insurance provider.

RETURNED CHECKS: A $50 returned check fee will be added to all returned checks and no future checks can be received as payment. If your returned check payment leaves a balance on your account that exceeds 30 days without repayment, you will receive a notice informing you that your account is overdue. If you do not pay your balance or arrange a payment plan within 15 days of notice, your account will be turned over to a collections agency. If this happens, a collection fee (currently 39% of the balance) will be added to your account balance. The collection agency will report any unpaid balance to the major credit bureaus.

CANCELLATIONS/MISSED APPOINTMENTS: An appointment in our schedule is a bond of trust that we will be here to serve you and you will be present for treatment. We request a 48 Hour Noticefor cancelling or rescheduling an appointment. When a 48-hour notice is provided, your reserved time can be made available to another patient. When patients no show appointments, rebook for a shorter service, or do not give an adequate cancellation notice we miss out on an opportunity to help another patient with their dental needs.

AFTER THE FIRST CANCELLED/RESCHEDULED/MISSED APPOINTMENT (without proper notice), a $50 cancellation fee will be added to your account.

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

CHANGE IN TREATMENT PLAN: Any change of scheduled treatment plan without 48-hour notice will result in a $250 fee added to your account balance.


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