LOCATED IN HEART OF VERRADO
LOCATED IN HEART OF VERRADO
PROFESSIONAL AND FRIENDLY STAFF
STATE OF THE ART EQUIPMENT

IF YOU HAVE A MEDICAL EMERGENGY DO NOT SEND CONTACT REQUEST.

Call office during hours of operation OR go to the hospital emergency room.
Emails are handled Monday-Friday 8:30am-5pm ONLY.

WELCOME…..These forms were created to help our team learn more about you, your wishes and needs.
Please read through and complete each section which pertains to you. Thank you.

 

 
  • PLEASE NOTE: Our greatest compliment is a referral. As a thank you, when referring friends or family, we offer a $25.00 gift certifi cate/credit towards future treatment. Please take just a moment to fi ll in this portion of our form.
  • As a condition of your treatment by this offi ce, fi nancial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and fi nancial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental services performed without previous fi nancial arrangements, must be paid for in cash or credit card at the time services are performed. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. Dental Insurance Or “Dental Assistance,” as it should be called, is designed to help pay part of the cost of dental treatment. Dental insurance is NOT designed to pay all the cost of treatment, but rather to be an aid. Your insurance contract is between you and your insurance company. We try to help you receive the benefi ts that you are eligible for. This offi ce will help prepare the patients insurance forms or assist in making collections from insurance companies – in return we must ask for Patient’s Portion to be paid before or at time services are performed. All co-payments or patient’s portion must be paid before patient is brought back to treatment room. I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination. In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within fi ve (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form. I have read and understand Notice of Privacy Practices.
  • There will be a $75.00 fee for any appointments that are scheduled and missed for any reason other than a true hardship emergency. 48 business hours notice is required to avoid the above fee.
  • Everyone’s time is valuable. We have many patients to care for. A missed appointment could have been time given to a patient in need. I have read the above conditions of treatment and payment and agree to their content.
 

 
  • If you are wearing a partial or complete artificial denture, please complete the following.
 

 
 

 

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