I consent to be a patient at the above named office and agree to a radiographic and clinical examination. I also understand and consent to the following:
24 HOURS NOTICE IS REQUIRED FOR ALL CANCELLATIONS! A $30 BROKEN APPOINTMENT FEE WILL BE CHARGED TO ALL ACCOUNTS WITH LESS THAN 24 HOURS NOTICE AND FOR ALL NO SHOWS!
The following is an outline of our office payment policies. Please acquaint yourself with them and then sign below to acknowledge your understanding and acceptance of them.
Please feel free to discuss our fees with us at any time. Before any dental treatment begins, the patient and/or responsible party will receive a consultation regarding treatment plan and cost. We attempt to keep our fees at a fair level that reflects the quality of care provided in our office. Prompt payment will enable us to keep our fees lower for everyone; therefore, payment is due at the time services are rendered. For procedures that take multiple appointments to complete, payment may be split up over the number of appointments required, however full payment must be remitted before delivery of final restoration or appliance.
We accept cash, check (returned check fee $20), Visa, MasterCard, and American Express.
As a courtesy to our patients with insurance, we will file your insurance claim for you. We are currently in network with MetLife and Delta Dental. Please remember that the contract is between you and your insurance company, and your total balance in our office is always your responsibility. We have no way to guarantee the actual terms of your insurance policy. The insurance payment may not cover the fee charged in office. Disputes regarding reimbursement or the amount of reimbursement are between you and your insurance carrier.
Account aging begins the day your charges are incurred. Accounts that are ninety days past due will be turned over to a third party collection agency. This action will cause an additional fee of 45% of your unpaid balance to be added to your account. We dislike doing this and will do so only if all other efforts to collect your unpaid balance have failed. Once an account is turned over to collections, we will ask you to seek the services of another dentist and will no longer take responsibility for your family’s dental care.
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.