I understand that in order for us to provide direct billing to our patients, we will require our patients to provide us with a credit card on file. If we cannot calculate your balance at your dental visit, we will charge the balance to the credit card on file upon receiving payment from your insurance company
If you do not wish to leave your credit card on file with us, you will be required to leave a 25% deposit following your appointment with us. This alternative may result in a small balance or credit on your account once insurance payment is received. It is important for you to understand that there may be a difference between our fees and what your insurance company will pay towards your treatment, and that you are responsible for any difference in fees.
Also I give consent to perform the dental and oral procedures deemed necessary for any treatment, including the use of local anesthetic and that I assume responsibility for the fees associated with those procedures.
If you are in understanding with each statement, please indicate by signing below.
To the best of my knowledge, the above information is correct: