Newberg Kids' Dentist Introduction (Page 6 of 6) in pdf

Newberg Kids' Dentist Introduction Page 6

Financial P olicies a nd A greement

Payment/Insurance P olicy

As a c ourtesy, w e f ile i nsurance c laims f or o ur p atients. A ll e stimated p atient p ortions a re d ue a t t ime o f s ervice. T his a mount

is a n e stimate o f y our c opayment a nd w e w ork h ard t o m ake t his a s a ccurate a s p ossible.

Our o ffice a ccepts c ash, c heck, V isa, D iscover a nd M astercard. W e a lso o ffer f inancing t hrough C areCredit a nd I n-‐House

financing.

Missed A ppointment P olicy

We w ork d iligently t o s ee a ll o ur p atients i n a t imely m anner. M issed a ppointments l eave u s w ith h oles i n o ur s chedule t hat

prevents u s f rom p roviding t imely c are f or t he c hildren i n o ur c ommunity. M issed a ppointments h urts e veryone. T herefore, w e

have i nstituted a “ Missed A ppointment P olicy” w hich s tates t hat a ppointments n ot c ancelled w ithin 4 8 h ours m inimum

advance w ill b e c harged a f ee o f $ 50.00.

Missed O ral S edation a nd O perative A ppointments

Due t o t he h igh d emand f or c onscious s edation a ppointments, w e h ave i mplemented a “ Missed S urgical/Operative

Appointment P olicy” t o e ncourage p atient t o k eep t heir a ppointments. I f y ou c annot a ttend y our s cheduled a ppointment, y ou

must c all a m inimum o f 7 2 h ours i n a dvance. I f w e d o n ot h ave a 7 2-‐hour a dvance n otice o f c ancellation, y ou w ill b e c harged a

$200 n on-‐refundable “ Missed S urgical/Operative A ppointment F ee”.

I u nderstand t hat I a m r esponsible f or t he p ayment o f a ll f ees f or d ental t reatment t hat a re n ot c overed b y t he p atient’s

dental o r m edical i nsurance. T he u ndersigned a grees t hat s hould t he a ccount b e r eferred t o a n a ttorney o r c ollection a gency

for c ollection, t he f ees i ncurred w ill b e p aid b y t he r esponsible p arty.

Parent/Legal G uardian S ignature

Date

Newberg Kids' Dentist Introduction Page 6