Patient Financial & Office Policies Acknowledgment

Patient Acknowledgment Our goal is to provide high-quality dental care in a respectful, efficient, and transparent environment. Please review and initial each section below to acknowledge your understanding. Insurance & Payments Dental insurance is a contract between the patient and the insurance company. As a courtesy, we submit insurance claims on your behalf; however, payment of copayments, deductibles, and non-covered services is due at the time of service. Insurance estimates are not a guarantee of payment. Any balance remaining after insurance processes a claim is the patient's responsibility.(Required)

Patient Acknowledgment
Our goal is to provide high-quality dental care in a respectful, efficient, and transparent environment. Please review and initial each section below to acknowledge your understanding.

Insurance & Payments
Dental insurance is a contract between the patient and the insurance company. As a courtesy, we submit insurance claims on your behalf;
however, payment of copayments, deductibles, and non-covered services is due at the time of service.
Insurance estimates are not a guarantee of payment. Any balance remaining after insurance processes a claim is the patient's responsibility.

I acknowledge that I have read and agree to the terms above.(Required)

X-Rays & Diagnostic Records Dental X-rays are an essential diagnostic tool and allow us to identify conditions not visible during a clinical exam. X-rays are taken only when clinically necessary and according to professional guidelines. X-rays from another office may not be usable due to age, quality, or diagnostic requirements. While we respect patient preferences, X-rays are required at appropriate intervals to provide safe and complete dental care and cannot be declined indefinitely. Refusal of necessary X-rays may limit our ability to provide treatment.(Required)

X-Rays & Diagnostic Records

Dental X-rays are an essential diagnostic tool and allow us to identify conditions not visible during a clinical exam.

X-rays are taken only when clinically necessary and according to professional guidelines.

X-rays from another office may not be usable due to age, quality, or diagnostic requirements.

While we respect patient preferences, X-rays are required at appropriate intervals to provide safe and complete dental care and cannot be declined indefinitely. Refusal of necessary X-rays may limit our ability to provide treatment.

I acknowledge that I have read and agree to the terms above.(Required)

Provider Scheduling Appointments are scheduled with specific providers based on treatment needs, clinical expertise, and availability. At times, care may be provided by a different doctor or hygienist to ensure timely and appropriate treatment. We make every effort to accommodate preferences; however, clinical needs and continuity of care take priority.(Required)

Provider Scheduling

Appointments are scheduled with specific providers based on treatment needs, clinical expertise, and availability.

At times, care may be provided by a different doctor or hygienist to ensure timely and appropriate treatment.

We make every effort to accommodate preferences; however, clinical needs and continuity of care take priority.

I acknowledge that I have read and agree to the terms above.(Required)

Appointments & Communication Please arrive on time so we can provide the best possible care. Late cancellations and missed appointments create a significant disruption to our schedule and limit our ability to provide care to other patients. After multiple missed or late-cancelled appointments, we may be unable to continue scheduling future appointments. We welcome questions at any time and are happy to explain treatment recommendations, insurance estimates, or office policies.(Required)

Appointments & Communication

Please arrive on time so we can provide the best possible care.

Late cancellations and missed appointments create a significant disruption to our schedule and limit our ability to provide care to other patients. After multiple missed or late-cancelled appointments, we may be unable to continue scheduling future appointments.

We welcome questions at any time and are happy to explain treatment recommendations, insurance estimates, or office policies.

I acknowledge that I have read and agree to the terms above.(Required)

Final Acknowledgment

I have read, initialed, and understand the information above regarding my dental care, appointments, insurance, and financial responsibilities. I acknowledge and agree to these policies.

Patient Name:(Required)

First Last

Signature:(Required)

Your Name
Your Name
Your Name

Date:(Required)

Monday	8am- 5pm
Tuesday	8am–5pm
Wednesday	Closed
Thursday	9am–6pm
Friday	8 am-5 pm (Closed one Friday per month)
Saturday	8 am-2pm (*Only one Saturday per month)
Sunday	Closed