Welcome to East Orchard Dentistry! Please take a few minutes to review our office polices. PAYMENT 1. Payment is expected at the time of services rendered. 2. Insurance forms will be filed, but patient out-of-pocket expenses are expected to be paid at the time of services. The patient is responsible for the services not covered by the insurance company. 3. It is the patient responsibility to know any exclusions or limitations with their insurance policy. 4. Patient accounts over sixty (60) days are subject to a 1.5% interest rate per month. 5. We now offer Care Credit as a payment option. FAILED APPOINTMENTS 1. A twenty-four (24) hour notice is required for all cancellations. 2. Possible dismissal from the practice or a charge of $65 would be the result of two failed appointments without a 24-hour notice. CONSENT FOR PROPHYLAXIS IN DENTIST'S ABSENCE --Situations may occur which prevents the dentist from being present in the office. The dental hygientists are licensed to practice on QUALIFYING patients in the dentist's absence with your approval. DENTAL AND MEDICAL HISTORIES It is the patients's responsibility to provide us with any current x-rays from a previous office. If no x-rays are provided, we will take necessary films for proper diagnosis. Please initial and type full name and DOB. *
