Office Policy 

OFFICE POLICY OFFICE HOURS Monday-Thursday 8:00 a.m. - 4:00 p.m. Friday Closed • APPOINTMENTS We reserve appointments very carefully so you will receive the doctor or hygienist’s full attention. Should you need to change your appointment, we ask that you call us directly so we can reschedule with you personally rather than leaving a message on the answering machine. Please give us the courtesy of 48 hours notice if you are unable to keep a scheduled appointment. This allows sufficient time to schedule another patient. A fee of $50.00 will be assessed for disregarded appointments without 24 hours notice. • INSURANCE Our agreement for service is with you, our patient, and not the insurance company; however, we do accept assignment of benefits as a courtesy to you. We do our best to estimate insurance benefits based on the information available to us, but we cannot predict how an insurance company chooses to reimburse for a given procedure. Insurance benefits are paid based on available benefits, contract limits and frequency limitations. Please be informed as to your insurance carriers policies or limitations regarding “downgraded” or “allowable” materials for restorations of fillings and crowns. Your estimated patient share is always due at the time of service. • BILLING As insurance payments are received, we will credit them to your account and any remaining unpaid balance will be billed to you the patient. We accept insurance assignment as a courtesy to you. All charges are your responsibility and will be included in the treatment estimate when treatment options are presented. • REFERRALS We are pleased that you have chosen our office to give you a healthy and attractive smile. We would be delighted to serve your family and friends. THANK YOU FOR YOUR CONFIDENCE AND SUPPORT IN OUR SERVICES!_____ I AgreeFirst Name:Last Name:Date of Birth