Payment Options & Arrangements Form

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Patient Information

Taking great care of your children is our top priority. We are committed to providing comprehensive home care instructions and dietary advice to help prevent your child from developing tooth decay. Likewise, when it does occur, we are dedicated to treating dental disease in the earliest stages, to prevent acute toothaches and emergency trips to the dentist. So we hope you agree, baby teeth are important because of the important job they do in helping the permanent teeth come in as they should.

At the onset of your child’s treatment, we will provide you with an estimate of total fees expected. Please understand that it will be an ESTIMATE only. Treatment sometimes changes for a variety of reasons. When it comes to estimating insurance payments and coverage, we must also stress that the word estimate, as insurance companies continues to surprise us at times. If the insurance company(s) pays more then expected, you will receive a credit. If they pay less then expected, a balance due will be reflected on your statement. If they deny your eligibility after the fact, or do not pay within 60 days, the balance becomes your responsibility. You may then use any other options below to pay your balance.

In the meantime, we ask that you review the following options, and indicate which payment option you think will work best for you and your family. If you choose the Monthly Payment Plan with Care Credit, we can process the application in our office in just a few minutes. Most of the time we can get tan answer that very day. We are here to help you afford your family’s dentistry and welcome your call at any time to explain both your treatment and financial options.

Payment Options

Thank you for reviewing our financial options and indicating your choice of payment. We appreciate the confidence you have placed in us, in caring for your children and remain available to you at any time to assist with your account.

I have chosen the option above, and accept full financial responsibility for this account. I understand that any insurance estimate given to me by this office is not a guarantee of actual insurance payment or coverage. I also understand that I am ultimately responsible for all chargers incurred for dentistry preformed upon myself or my dependents in this dental office. Any insurance claim(s) not paid in full after 60 days will become my responsibility to pay at that time. I also understand that if someone else brings my child for treatment, they will be prepared to pay what is due. Those people may be:

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