New Patients

I am aware that fees for dental services, which include unpaid balances, deductibles and co-payments, are due at
the time of service unless other arrangements are made in advance.
If I have dental benefits, I am aware that as a courtesy to me, this office will prepare forms and submit necessary
documents to my benefit company. However, I realize that my benefit policy is a contract between me, my employer and the
benefit company, and that I, not my benefit company, am ultimately financially responsible for all charges for treatment
rendered. If my dental benefit company does not pay within 60 days, I agree to accept responsibility for any unpaid balance.
I realize that accounts which are not paid within 30 days after being billed are subject to a 1% per month (12% per
annum) finance charge on the unpaid balance. Overdue or unpaid accounts may be turned over to a collection agency, and I will be responsible for all of the costs of collection, including court costs, collection agency fees and attorney fees.
I understand the above policies and accept responsibility for myself or patient: