Check all that apply.

Check all that apply.

We are a non-assignment practice. We will, however, be more than happy to submit any and all forms to your insurance provider electronically and on the day of service. This will ensure reimbursement as quickly as possible. We will estimate your portion based on the most up-to-date information we have, but it is ONLY AN ESTIMATE. If you would like to know your exact insurance benefit, we will be happy to file a “pre-treatment authorization” with your insurance company prior to treatment. This does delay treatment but will give you the exact out of pocket figures you require.

We bill your insurance as a courtesy. However, it is important to recognize that the insurance you have is a legal contract between you and your insurance company. Our office is not, and cannot be a part of that legal contract. Ultimately, you are responsible for all charges incurred in our office.

Due to a continuous high demand in prime appointments, we require a minimum of 48 hours notice per appointment to cancel or reschedule. In the case that insufficient notice is given, a $50 cancellation fee per 1/2 hour will be applied to your account and must be paid in order to schedule future appointments (emergencies are an exception).

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge and I thoroughly understand the office policies as set out above. I will notify the doctor of any changes in my medical status or medication. In addition, I hereby authorize the doctor to take x-rays, CT scan, study models, photographs or any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of my dental needs.