As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for by cash, debit, MasterCard, or Visa at the time services are performed.

Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any collections to the patients account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

I understand that any fee estimate for this dental care can only be extended for a period of three months from are date of the patient examination.

I understand that I am financially responsible for the outstanding balances for services provided, including all of those that are not fully covered by insurance. I consent and agree to be financially responsible for the payment of all services rendered on me behalf or on behalf of my dependents (if any).

I grant my permission to you or your assignee, to telephone me to discuss this statement or my treatment.