Forms & Policies

New Patients Forms

Please click here to access our patient forms.

Financial Policy

The following is a statement of our office policies, which we ask you to read and sign prior to any treatment.


For un-insured patients, payment in full is due at the time of service. For insured patients, the insurance co-pay and deductible are due in full at the time of service. To accommodate you, we accept:

For extensive treatment plans we offer extended payment plans with prior credit approval, thru Care Credit.We also offer 10% courtesy for payment in full at time of treatment with cash or check only.

Regarding Insurance

We will accept assignment of your insurance benefits. The balance of your account is your responsibility whether your insurance company pays for your treatment or not. We will gladly process your claims provided you give us accurate insurance information. It is the patient’s responsibility to inform us of any changes in insurance coverage prior to receiving treatment.

Your insurance is a contract between you and your insurance carrier. Please be aware that some, and perhaps all, of the services provided may be non-covered services and/or not considered reasonable or necessary under the policy your employer has selected. Please note that if a service is not covered, the full financial responsibility rests with you.

Why Doesn’t My Insurance Pay for This?

Employers offer dental benefits to help employees pay for a portion of the cost of their dental care. Dental plans are designed to share in the cost of your dental care, not to completely pay for those costs. Almost all dental benefit plans are the result of a contract between the plan sponsor (usually an employer or a union) and the third-party payer (usually an insurance company). The amount your plan pays is determined by the agreement negotiated by your employer with the insurer. Your dental coverage is determined not by your dental needs—but by how much your employer contributes to the plan.


Our office charges a $25.00 fee for missed appointments: therefore, cancellations must be received 2-business days prior to an appointment in order to avoid being charged.

Thank you for taking the time to read and understand our financial policy. Our practice is committed to providing the best treatment for our patients. Please let us know if you have any questions. Any of our staff members would be glad to review the financial policy with you at any time.