We are committed to providing you with the best possible care, and we are pleased to discuss our professional fees with you at any time. Your clear
understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about fees, financial policy or your
responsibility.

1. Payment is due at time of service (pre-pay is required for all Saturday appointments) and a deposit of $45 per hour of appointed time is required for reserving
an appointment. This deposit may be forfeited if proper notice (48 hours) is not given to reschedule/cancel an appointment. A credit card can be kept on file to pay
your portion of services if another form of payment is not presented.

2. If insurance is involved, co-payment and any deductible are to be paid at the time services are rendered. Your deposit will be credited toward your services if
your reserved time is in good standing.

3. We accept cash, check, MasterCard, VISA, Discover, and American Express. Dental insurance should be regarded as dental assistance. It is designed to help
pay some of the costs of dental treatment.

Because there are so many dental insurance companies and programs it is nearly impossible for us to have complete knowledge about all of them, or your status with your particular company. We will do our best to help you maximize your benefits. Dental insurance is meant to be a partial aid to defray professional fees. It is not designed to pay all the costs of dental treatment, Insurance is a contract between you and your insurance company. We are typically not a party to this contract. If we are, we will inform you and handle the claim according to our agreement with the insurance company. We file insurance as a courtesy to our patients. We will not become involved in disputes between you and your insurance regarding deductibles, copayments, covered charges, secondary insurance and other matters regarding reimbursement. The kind of benefits in your contract depend on what you and your employer have negotiated with the insurance carrier, and the amount of money you choose to pay in premiums. Returned checks will receive a $25.00 overdraft charge. A the time of your initial appointment, please bring your insurance card and photo identification. Your portion of the fees less your deposit, if the reserved time is kept in good standing can then be computed and paid at the completion of your appointment. If the insurance payment varies from the computed amount, an adjustment will be made. If care is being rendered on a minor child, the parent or guardian who accompanies the child to the appointment is financially responsible for the account. You are responsible for timely payment of your account. Thank you for understanding our financial policy. Please let us know if you have any questions or concerns.

I understand that I am responsible for all costs of dental treatment regardless of what my insurance carrier may or may not pay. This signature will also serve as signature on file for assignment of insurance benefits. in the event of any default regarding charges incurred, the debtor will be obligated to pay all collection costs and/or attorney fees incurred by E-Care Dentistry in the collection of these charges.