Capitola Dental · P|831-475-2313 · 617 Capitola Ave, Capitola CA, 95010 · ·
Signature will be recorded later.
Date: 8/4/2020DOB:Financial AgreementWe are committed to providing you with the best possible dental care. For patients with dental insurance, we would like to help you receive your maximum allowable benefits. We will discuss your proposed treatment with you and let you know what your insurance is estimated to cover. Not all services we provide are covered benefits for all insurance contracts. Some insurance companies arbitrarily select certain services they will not cover. Your dental needs may not correspond with your insurance coverage. Payment for services is due at the time services are rendered unless payment arrangements have been approved in advance by our staff. We accept all major credit cards and Care Credit, with the exception of American Express. For your convenience, we will be happy to submit insurance claims on your behalf. For those patients with dental insurance, the estimated portion of charges that the insurance will not cover is due at the time of service. The estimated portion is an estimate only; our office always recommends that patients contact their insurance company directly for the exact amount of coverage for a particular dental procedure. We require a minimum of 24 hours notice for all cancelled or rescheduled appointments. A cancellation fee of $50 is charged for all appointments where 24 hours notice is not given. As dental care providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy we extend to our patients, all charges are your financial responsibility. We realize that temporary financial problems may affect timely payments on your account. If such problems do arise, we ask that you contact us promptly for assistance in the management of your account.Last Name:First Name:Dr. Robert C. Schellentrager DMD General and Cosmetic Dentistry