We require at least 24 hours notice to cancel an appointment. Any missed appointment will result in a $20.00 fee, which will need to be paid prior to any future appointments.
By signing this form, you agree that you understand that all charges for orthodontic treatment are due and payable at the time services are rendered, unless prior arrangements have been made. By signing this form, you also agree to authorize insurance benefits to be paid.
You agree that insurance portions are ESTIMATED based on information released by your insurance company. However, the estimate amount of insurance is NOT a guarantee of payment. You are aware that the insurance is a contract between yourself and your insurance carrier/provider. As a courtesy, claims may be filed on your behalf. If for some reason the insurance does not cover the benefit we have estimated, that difference will become the responsibility of the patient/parent/guardian.
You understand that you are financially responsible to the doctor(s) for all treatment.
Returned checks will result in a $35.00 charge to your account. In that case, only cash or credit card payments will be accepted from that point forward.
Cell phones are not permitted in the treatment areas. Video recording is strictly prohibited.
