• I understand that it is my responsibility to know my dental insurance benefits and coverage.


  • I understand that payment is expected at the time services are rendered, unless prior financial arrangements have been made.
  • A 1.5% finance charge will be assessed monthly on all unpaid balances.
  • I understand that if my account becomes delinquent, I will be turned over to a collection agency and I will be responsible for any collection costs and legal fees.
  • I understand that if I have a delinquent account, I will be denied all treatment, except in case of emergencies.

Missed Appointments
We understand that sometimes circumstances arise that prevent patients from keeping appointments. Please call us within 24 hours or one business day to let us know that you will be unable to keep the appointment. With advance notice we can let another patient have the time that was reserved for you. This also allows for our staff to plan and use their time effectively. After two missed appointments without notice, you will be charged a $35.00 fee for our time. If a third appointment is missed without notice, you will be dismissed from the practice.