I understand the above information is necessary to provide me with dental care in a safe and effecient manner. I have answered all questions to the best of my knowledge. Should further information be needed, this office has my permission to ask either me, the respective care provider or agency, who may release such information to you. I will notify the doctor of change in my health and medication.
As a condition of your treatment by this office, all copays are due at the time of service. Our office does offer and extended payment plan through Care Credit with prior arrangement. Please ask a member of our staff for more information on this. We also accept Visa, Mastercard, American Express & Discover for your convenience.
Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will file your claim to your insurance company and will credit any such collections to the patient's account.
Minor Patients MUST be accompanied by an adult for the duration of all appointments. The adult accompanying a minor is responsible for providing up to date and accurate insurance information to our practice, as well as payment. (Under 18 years of age)
Our office reserve the right to charge a fee for broken appointments without a 24 hour advance notice of cancellation.
In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay for said services to said Doctor, or his assignee, at the time said services are rendered.
By clicking the submit button below, I am filining my signature electronically for this agreement.