Payment Policies

General Policy

Payment and co-payments are due in full on the day you receive dental services. We accept cash, checks, all major credit cards: Visa, Master Card, American Express, Discover.

Dental implants we require full payment on the day of service.
Mouth guards or partial dentures, we require 50% deposit on the day impressions are taken.
Crowns, veneers or full dentures, these procedures normally require more than two appointments, as a courtesy we will accept payments to be split between the number of appointments to finish the treatment.
At your final appointment to receive your crowns, veneers or full dentures, we will ask you for final payment in full.

Dental Insurance

With the exception of some preventive procedures such as cleanings and x-rays, your dental insurance company will not fully cover the cost of the treatment. You are responsible for the portion they do not cover, payable on the day you receive treatment. Typical reimbursements by insurance companies range from 40%-65%.

Some insurance companies, including Delta Dental and Blue Cross/Blue Shield will not reimburse you for white composite fillings. Instead, they reimburse you for less expensive silver/amalgam fillings. If you have one of these plans, you may be responsible for up to 60% of the cost of these fillings.

Most dental insurance plans have a maximum yearly benefit of $1000, while some plans may be more. We cannot submit work done in one calendar year for the next calendar year.

Most dental plans have a deductible that you must pay each year, typically $50. Usually the deductible does not apply to preventative treatment.

Since we administer hundreds of employer benefit plans, we cannot know the details of every plan. It is the patient's responsibility to know the details of their coverage. To submit an insurance claim, you must present a dental benefit card with your group number on it.

Acceptance Agreement

I understand and agree with the above payment policy. I understand the parent or relative bringing a child in for dental treatment is responsible for all fees incurred at that visit.

In further understand that I am responsible for ALL fees, regardless of insurance coverage.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.