Financial Agreement Financial Arrangement By having flexible and consistent payment arrangements, our office can focus on our specialty of providing you with superior customer service, optimal dentistry, a comfortable environment, and state of the art technology while keeping our fees as low as possible. Payment Options/Savings Opportunities Please check below each financial option you would like to discuss with our financial coordinator or that you feel applies to you: Military Valor Discount: A 10% courtesy discount is given to families currently in the armed forces and individuals with prior service record. This discount is reduced to 7.5% when using credit cards and 5% when financing to offset our costs. Prepayment Discount: A 5% courtesy discount is given when entire cases are prepaid by check, in full, as arranged by our financial coordinator. True No-Interest Financing: Pay over 6 or 12 months with no interest. Extended Financing: Low monthly payments ranging from 24-84 months, with interest. Credit Card/Debit/Check: Date of service payments. Untitled Treatment Fee Estimates and Insurance Coverage We will always make every effort to explain all anticipated fees in advance. Two primary variables are out of our control; complexity of oral conditions and insurance reimbursements. Treatment costs can change during procedures and will be counseled when faced. If you have dental benefits, we will estimate your out of pocket costs and payment will be due at time of serviceUntitled Appointments, Timeliness, and Communications We are committed to seeing you on-time for your reserved appointment and request that you arrive on-time for your visits as well. We expect at least 1 business day notice be given if an appointment needs to be rescheduled. You will incur a fee of $50/hour reserved if insufficient notice is given. Please, feel free to contact us if you have any questions or concerns regarding your dental treatment or financial arrangements. It is our pleasure to serve you as our patient and we want you to have any and all financial questions clarified.Untitled Credit Card Convenience In order to streamline our billing processes, we will reserve a credit card on file using our secure server. This card will be used in two circumstances: Credit Refund: If a credit due to overpayment is on your account, we will process a refund to bring your balance with us to zero. Debit Charge: If a balance remains after insurance payment, we will process a debit from your card to resolve your balance. Any charges above $250 will be verified via phone before processed. Please have card ending in (last 4 digits) and expiring on (fill in the space provided) ready for our financial coordinator to file on our secure server. Yes, I consent No, I Opt Out Untitled Certification I certify that I have read and understand the above information to the best of my knowledge. My health history questionnaire has been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my dependent during the period of such dental care to third part payors and /or health practitioners. I authorize and request my dental benefit company (and medical insurance if applicable) to pay directly to the dentist unless otherwise specified. I understand that my dental benefits will not cover 100% of all dental expenses. I agree to be responsible for payment of all services rendered on my behalf or my dependents that are not covered by my dental/medical benefits. Patient Name (Print) Responsible Party (Print, If Applicable) SignatureDate MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged.