Dental History (Page 4 of 4) in pdf

DDS, FAGD

R I A N

U R T R Y ,

Fellow of the Academy of General Dentistry

Family & Cosmetic Dentistry

10816 Black Dog Lane, Suite 100

Phone: (704) 392-3883

Charlotte NC 28214

Fax:

(704) 392-3893

Email: drmcmurtry@bellsouth.net

Financial Policy

Thank you for choosing our office for your dental needs. We realize that every person’s financial situation is different. For this reason, we have

worked hard to provide a variety of payment options to help you receive the dental care you need and deserve that allows you to enjoy a healthy,

beautiful smile with respect to your budget. Dental treatment is an excellent investment in an individual’s medical and psychological care. We are

always available to answer your questions or assist you in any way we can.

To maintain the practice operations and prevent potential misunderstandings, we ask patients to accept and adhere to the following financial

arrangements regarding their dental treatment.

Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. In the event we do accept

assignment of benefits and your insurance company has not paid your account in full within 60 days, the balance may be transferred to your account.

Please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and customary

under the terms of your insurance policy. Our practice is committed to providing the best treatment for our patients and we charge what is the usual

and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary

rates.

Payments are expected at the time services are rendered. We accept cash, checks (under $500.00 ), debit cards, Visa, Mastercard, and American

Express credit cards. Returned checks are subject to a Non-sufficient funds fee issued by your bank AND our bank.

Check payment over $500 is only accepted for pre-payment of treatment and for patients with an established payment history.

Optional Payment Terms:

Bookkeeping Discount: If you have a treatment plan totaling $4000 or more, a 5% discount will be applied if the treatment fee is paid in

full prior to the start of treatment. This applies to patients paying in cash or check. This discount is not given if paying via Care Credit.

Term Loan: By arrangement with Care Credit, we offer our patients, upon approval, an interest-free term loan (up to 24 months) with no

down payment, no annual fee, and no prepayment penalty. Longer payment terms are available at a nominal interest rate. Please ask for

an application.

Broken appointments: A broken appointment is defined as an appointment that is cancelled or rescheduled with less than

48 business hours notice. (Business hours are Monday through Thursday). No-shows are also broken appointments.

A specific amount of time is reserved especially for you and we strongly encourage all patients to keep their appointments.

We do not double or triple-book patients. If you do not show up for your appointment, there is no other patient for us to see.

We do not accept appointment cancellations through text or email within 48 business hours.

Broken appointment fees:

This is not intended to scare off patients but to stress the importance of keeping an appointment that you, the

patient, has scheduled with us.

Hygiene Appointments: $55.00. Includes regular check-ups, regular cleanings, and periodontal maintenance

Periodontal Services with hygienist (Deep Cleanings, Deep Scalings) : 25% of the full treatment fee (not your co-pay)

Dr. McMurtry’s appointments: 25% of the treatment fee (not your co-pay but the full fee of the visit)

We understand that emergencies may arise. At our discretion, a broken appointment fee may be waived due to these unforeseen circumstances.

Thank you for understanding this financial policy. If you have any questions concerning this, please ask before signing and accepting this policy.

____________________________________

________________________________________________

______________

Patient Name (Print)

Patient/ Guardian Signature

Date

____________________________________

Additional family member (minor child)

____________________________________

Additional family member (minor child)

Dental History Page 4

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