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Financial Policy Form

Financial Policy

Thank you for choosing us as your health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. We have listed our office guidelines to help you get an understanding of our financial policy. We ask that you read and sign this agreement prior to any treatment.
All patients must complete our patient registration information form before seeing the doctor.


  • We accept cash, checks, Visa, MasterCard, Discover and Care Credit.
  • Full payment is due at the time of service.
  • Insurance deductibles and co-payments are due in full at the start of treatment.
  • Budgeted contractual arrangements may be offered with prior credit approval with Care Credit.

Budgeted contractual arrangements may be offered with prior credit approval with Care Credit.

Due to increased number of dental insurance plans and recent changes to coverage benefits, we are not able to guarantee dental coverage in our office.
As a courtesy to our patients, we will bill your insurance company, but any rejected claims or balances will be the patient’s responsibility.
Any questions regarding coverage should be directed to your insurance company or human resource department.


Our practice is committed to providing the best treatment for our patients. We charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. Our fees are based on the treatment selected, the time needed to provide you with the necessary dental care and the overhead in our practice.


Please help us serve you better by keeping your scheduled appointments. You must give the office 48 hours notice for cancelled appointments. Same day cancellations are considered broken appointments. There will be a $75 charge applied to your account at the second broken appointment.


Any expense incurred for returned checks, legal fees and collection agency fees will become your responsibility and will be added to your account balance. Past due balances over 60 days will be assessed a $10 billing fee for every billing cycle until balance is paid in full.
We are here to serve your dental needs and make your entire experience pleasant. We encourage you to discuss any financial concerns that you may have so that we may assist you in the effective management of your account.
I have read, understand and agree to the financial policy described above.


NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

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.