Metro Smiles Patient Agreement
Welcome to Metro Smiles! Your health, comfort, and convenience are important and we want you to feel at ease each time you are a guest here. Talk to us about any special concerns you have regarding your dental health and we will do our best to accommodate you. The greatest compliment our patients can give us is the referral of family members and friends!
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PREMIUM SERVICES
• Invisalign® Clear Aligners
• Therapeutic Xeomin® and Botox®
• Philips Zoom WhiteSpeed Professional Whitening
• QuickPro Instant Whitening
• Oral Care with Ultrasonic, Laser Bacterial Reduction, and Seal and Protect
• Metal-Free Cosmetic Dentistry including Composites, Crowns, Veneers, & Implant Crowns
• i-Tero® Element for Invisalign® Impressionless Scans

We reserve the right to select patients for our office and refer to specialists. All root canals and surgeries will be referred to our dedicated specialists. We do not offer Nitrous oxide for any procedures in office.

APPOINTMENTS
We reserve time specifically for you in our schedule. A two business days notice is required to allow for accommodation of other patients. Patients who fail to provide proper notice of missed appointments will be charged a fee or dismissed from the office.
INSURANCE
Your dental coverage is not based on what you need or what your dentist recommends. Your dental coverage is based on how much your employer pays into the companies' insurance plan. Sometimes you may have dental treatment that is not covered by your specific plan. Employers generally choose to cover some, but not all, of employees’ dental costs. Although insurance companies cover a percentage of most services, there are some insurance plans that do not. We make every effort to assist you in understanding your dental benefits. However, it is impossible for us to know all the many different employer group plans and specific benefit details. Therefore, we are providing this notice to inform you of the following responsibilities as they relate to benefit coverage and payment responsibilities by the patient.

Dr. Robin and the Metro Smiles team are NOT responsible for knowing what services will be covered by the individual patient’s insurance plan nor responsible for informing a patient whether a particular service is covered. We will assist patients in obtaining payment from their insurance by submitting necessary claims. As part of the financial arrangement process, we estimate your patient portion and ask you to pay at the time your services are rendered. If your insurance denies your claim or downgrades a procedure, the balance will be automatically transferred to you and you are responsible for complete payment.

PATIENT RESPONSIBILITIES
Our goal in discussing your financial arrangements is to create an understanding and partnership in settling your account. It is the patient’s responsibility to know and understand his/her dental benefit coverage and limits. Therefore, the patient is ultimately responsible for payment of all services at Metro Smiles.

Patients will be contacted for collection of any portion not covered by insurance or a remaining balance not paid within 30 days after insurance payment.

Payment options include: Cash, Debit Cards, Credit Cards (Visa, MasterCard, American Express, Discover), and Care Credit financing.


By signing below, I acknowledge I have read the above and understand and accept my responsibilities as a patient of Metro Smiles P.C.

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