Office Financial Policy

Thank you for choosing us as your dental health care provider. We believe that all patients deserve the very best dental care we can provide. We also believe that everyone benefits when specific financial arrangements are agreed upon in advance of any treatment. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment.

  • Full payment is due at the time of service.
  • Insured patients must pay estimated co-payments, deductibles, and uncovered procedures at the time of service
  • We accept cash, check, MasterCard, and Visa
  • Payment plans are offered only through CareCredit. There is no in house payment plan.


We require that any co-payments, deductibles, and any services not covered by your insurance plan be paid at the time the service. The balance is your responsibility whether your insurance company pays or not. We cannot bill your insurance unless you bring in all insurance information at your initial visit. Your insurance policy is a contract between you, your employer and an insurance company. We are not a party to that contract. If your insurance company has not paid your account in full within 45 days, the balance will be automatically transferred to your account. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. We do abide by fees set by insurance plans if we are in-network providers.

Adult Patients

Adult patients are responsible for full payment at the time of service. If you are unable to pay at this time, be sure to point this out when you arrive for you appointment.

Minor Patients

The adult accompanying a minor and/or the parents (or guardians) are responsible for full payment at the time of service. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit plan, credit card, or payment by cash or check at time of service has been verified.

Payment Plans

We accept Care Credit offering our patients 0% interest financing for 3, 6, 12 or 24 months with approval. No other payment plans are available.

Missed Appointments

Broken appointments are charged a fee of $35.00. Please understand that missed appointment times are valuable to patients that may find it hard to come to the dentist at other times. Please help us serve you better by keeping your scheduled appointments. Excessive cancellations and no shows will result in termination of our treatment agreement.


Balances that are 60 days old will incur a monthly 1.5% finance charge with equals an 18% per annum rate. There is also a $30 returned check fee.


Refunds for overpayment will be sent after all treatment is completed and insurance has been collected.


Any account that has not received payment in 90 days will be handed over to a collection agency that will pursue the responsible party for reimbursement. This will negatively impact your credit history and limit the treatment you can receive at our office.

Thank you for understanding our financial policy. Please let us know if you have any questions or concerns. We look forward to providing the highest quality dental care in a relaxing and caring atmosphere.

I have thoroughly read the Financial Policy. I understand and agree to this Financial Policy.

Printed Name:_________________

Signature: ___________________ Date: _____________

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