Download & Fill Out Our Patient Registration Form
New Patients:
We want you to feel comfortable with your dental care and that includes feeling satisfied with your financial arrangements. If you have any questions or concerns with this financial agreement please do not hesitate to contact us.
Dental Insurance:
As a courtesy we will gladly file your claims and accept assignment of dental insurance benefits provided you agree to the following:
•Although we may estimate your insurance benefits, we are not responsible for their accuracy. Knowledge of benefits as well as benefit amounts, limitations, exclusions, waiting periods, etc. is entirely your responsibility. Receiving our services indicates your acceptance of responsibility to pay regardless of our estimate.
•All charges not paid by your insurance are your responsibility regardless of the reason for nonpayment. Not all the services we provide are covered benefits. Benefits differ from one company to another. Fees for non-covered services, along with deductibles and co-payments, are due at the time of treatment unless other payment arrangements have been made.
Patients Without Dental Benefits:
We provide written estimates of fees and payment is expected at each visit for services rendered.
Minor Patients:
The parent or guardian accompanying the minor is responsible for full payment. In the case of divorced or separated parents, the accompanying parent is responsible. This office will not attempt to collect payment from a parent that is not present in the office at that visit.