Adult and Children’s Cleanings
Brushing and Flossing
Partial and Complete Dentures
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body.
Heath problems that you may have, or medication
Do you have, or have you had, any of the following?
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
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. Please understand that payment of your bill is considered a part of your treatment. We will, however, be sensitive to your financial circumstances working with you to maximize your insurance benefits and make any remaining balance easily affordable. Before treatment is performed, we will discuss treatment and financial options. This will allow you to fully understand your dental treatment, what to anticipate in fees and allow you time to make the necessary financial arrangements. Insurance benefits are determined by your employer, not your dentist. Your insurance policy is a contract between you and your insurance company. Your insurance coverage and benefits is your responsibility. Insurance is not a guarantee of payment; it often does not cover all the costs involved in treatment. As a courtesy, we will be happy to file your claim for you if you present your dental insurance wallet card and all required employer information.
Patients without insurance coverage need to know . . .
The fee for the treatment rendered must be paid in full on the day of service.
Patients with insurance coverage need to know . . .
The estimated patient copay and deductible for the treatment rendered must be paid in full on the day of service. Please understand that you are ultimately responsible for all fees generated by your treatment. Filing insurance claims is a service we provide free of charge, but in no way relieves you from the responsibility of your bill.
We accept Visa, MasterCard, checks, and cash for payment of the amount due.
Payment plans are available. Please ask about them if you need one.
Two business days notice is required for rescheduling appointments.
We do charge $50.00 for any broken appointments. Broken appointments are considered those that are missed (no-show) and cancelled with less than a two business day advance notice.