As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and
financial responsibility on the part of each patient must be determined before treatment.
All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.
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 help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office does
not render services on the assumption that our charges will be paid by an insurance company.
A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 30 days, unless previously written financial arrangements are satisfied.
I understand that the fee estimate listed for this dental care can only be extended for a period of 90 days from the date of the patient examination.
In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said
services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within five
(5) days. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs including the costs of
collection and reasonable attorney fees if suit be instituted hereunder.
I further acknowledge that I will pay fifty dollars ($50.00) per hour of time allotted for me or my dependent, in the event I do not give two (2) business days notice to reschedule or cancel any appointment I have made with this office. I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form. I grant my permission to you, or to your
assignee, to use any or all of my and my family’s previous and future reviews, written comments, using any electronic media format, any and all photographs, images, x-rays, casts and likenesses of any
kind for the purposes of education, promotion, or publication in any media format including all website and electronic media.