Please fill out our online Office Policy form or download and print our New Patient Registration Packet prior to your first dental appointment so we can expedite your first visit: If you download our PDF New Patient Registration Packet you will need Adobe Acrobat Reader to view the PDFs. Click here to download it.
Download Our PDF Print Version To Print, Fill Out and Bring With You To Your Appointment.
Welcome to our office. We are pleased that you have selected our office. We find that communication with our patients regarding our office policy assists us in providing the best service to you and helps avoid misunderstandings. Please sign at the bottom that you recognize and agree to these terms. Please feel free to ask us any questions.
We are happy to help you file the necessary forms to insure that you receive the full benefits of your policy; HOWEVER, we can make no guarantee of any estimated coverage. Your co-payment is due on the date of services rendered. Your insurance policy is an agreement between you, your employer, and your insurance company. We ask that all patients be responsible for services rendered in this office. Services provided must be paid for at the time of treatment. There is an interest rate charged of 1½ % per month to any account that is 45 days past due.
We respect your appointment time and take every effort to begin your treatment as scheduled. We request at least 48 hours’ notice to allow another patient to use the time that had been set aside for your visit. Failure to let us know of your cancellation 48 hours in advance will result in a $50.00 charge per hour to you.
If a check is returned to us for insufficient funds, a $25.00 service fee charge will be applied to your account. If you are forwarded to our collection agency, you will be responsible for all charges, including interest, late charge fees, collection fees, and attorney’s fees.
Thank you for taking the time to read this policy statement.
I (we) have read, understand, and agree to the above policy.
