In providing the highest quality of care to each of our patients, accurate scheduling is important. For that reason, we have created a cancellation policy to ensure that we can serve all of our patients in a timely manner. Our cancellation policy is as follows:
- You must provide at least 24 hours’ notice before the scheduled date and time of the appointment you are canceling.
- Appointments cancelled with less than 24 hours’ notice will be charged seventy-five dollars ($75). We understand unusual circumstances may occur and with written explanation the fee may be waived.
I acknowledge that I have read and understand this policy and agree to pay a seventy-five dollar ($75) cancellation fee if I provide less than 24 hours’ notice when canceling an appointment.
In the interest of good communication and our continued commitment to provide the highest quality of dental care available to all of our patients, we have established a Patient Financial Policy. It is our hope that this policy will facilitate open communication between us and help avoid potential misunderstandings, allowing you to always make the best choices related to your care.
We are committed to supporting you in understanding your dental health, and will always present you with the best dental solution possible to treat your personal situation. To make these services comfortably affordable, we are pleased to offer you the following payment options. Please select one:
- Cash, Check, Debit
- Visa, MasterCard, Discover, American Express
- 90 day Payment Plan
We will, as a courtesy, process your insurance benefits in our office. Specific questions regarding your insurance benefits must be addressed to your insurance carrier.
I agree that I am fully responsible for the total payment of all procedures performed in this office—this includes any treatment that is not a benefit of any dental insurance that I may have. I understand that any estimated portion, not covered by insurance, is due at time of service for all services rendered. I understand that all services are due to be paid within ninety (90) days of date of service, regardless of whether or not my insurance benefits have been received. One and a half percent (1.5%) per month interest, eighteen percent (18%) per year will be charged on accounts 90 days from the treatment date. I also understand that should credit be extended to me by this dental office, a credit check will be made through TRW or other credit services and I authorize release of all financial data.