Financial Policy

Please check each box to verify you have read and understand our financial policy.
  • PATIENTS WITH DENTAL INSURANCE:

  • PATIENTS WITHOUT DENTAL INSURANCE

  • FINANCIAL POLICY FOR ALL PATIENTS

    We bill monthly statements, up to 3 months. If payment is not received in full within 120 days, your account will be turned over to our billing agency, AR Services. Please further understand that a finance charge of 1.5% per month will be added to any overdue balance.
  • BROKEN APPOINTMENTS

  • AFTER HOURS EMERGENCIES

  • By signing below, I acknowledge that I agree and accept the financial policy as outlined. I authorize and request my insurance company to pay directly to the dentist all benefits. I understand that my dental insurance carrier may pay less that the actual bill for services. I agree to be responsible for payment of all services provided on my behalf or my dependents.
  • This field is for validation purposes and should be left unchanged.