Thank you for choosing us for your dental needs. We look forward to developing a relationship with you. Enclosed you will find registration forms that we need to assemble information for your chart. We will need a photo ID, such as a driver’s license, and any dental insurance cards. Please notify us if you have secondary dental insurance.
INSURANCE AND FINANCING If you plan on using your dental insurance, you may want to review your benefit book to better understand your coverage, because each plan us different. We are happy to review your plan with you if you have questions. As a courtesy, we will file your claim for you. Please be prepared to pay your co-pay and/ or any deductible at the time of service. We also require your authorization to receive payment from your insurance company, your signature below will authorize direct payment of insurance benefits to the dentist. We will you an estimate of your out-of-pocket expenses, but this is only as estimate. Your insurance company will determine your final benefits. You are responsible for any charges your plan does not cover.In the event your benefit company fails to pay your claim within 90 days, the remaining unpaid balance will automatically become your responsibility and be due in full.We have financing available. We are happy to discuss your options with you.
APPOINTMENTS AND CANCELLATIONS When we schedule your appointment, we are reserving a room for your particular needs. We ask that if you need to change an appointment, please give us at least 48 hours notice. Appointments canceled less than 48 hours in advance, as well as not showing up for a scheduled appointment, are considered broken appointments. Repeated cancellations and/ or missed appointments (more than two) will result in an office visit charge and loss of future appointment privileges. We understand emergencies arise, but please be courteous and notify us. We feel our patient’s time is valuable. When your appointment is made, a room is reserved, your records are prepared, and special instruments are readied for your visit. Except during emergency treatment for another patient, you can expect us to be prompt. I have thoroughly read and understand the above conditions of payment and agree to these conditions.