Thank you for choosing our office for your child's dental needs. Payment is expected at the time services are rendered; the parent who accompanies the patient to the appointment will be responsible for payments. If you are unable to be with your child at the time of his/her appointment, payment arrangements should be made prior to the dental visit.

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 for 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 patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 35% will be charged to those accounts that are delinquent and will be sent to collections.

I understand that any fee estimate for this dental care can only be extended for a period of sixty (60) days from the date of the patient examination. Because your insurance company makes no guarantee of payment, we cannot always guarantee your exact insurance coverage. Therefore, you may receive a statement with an additional balance after your insurance has met their obligation. In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.