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Financial & Cancellation Agreement
At Puget Sound Dental Clinic, we believe that you deserve the best care. In order to start the dental care that you deserve, we require you to be financially responsible for your treatment. The following is a statement of our Financial Policy that we require you to read and sign before any treatment is rendered.
Fees and Payments:
We make every effort to keep down the cost of your oral health care. All payments are due at the time of service. We accept all major Credit Cards, cash, and checks. An estimate of the charges for any procedure or surgery will be provided to you prior to any dental treatment. If you have any dental and/or medical insurance, we will be glad to fill out the proper forms. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. If your insurance does not pay within 45 days, Puget Sound Dental Clinic reserves the right to request payment in full for services from you.
Appointments are reserved to accommodate you, the patient, and your treatment to be performed. Therefore, we require at least 24-hour notice prior to canceling or rescheduling appointments. Unconfirmed appointments within 24hrs will be automatically removed from the schedule. Broken appointment without proper notice will be assessed a $50 fee to offset the lost production time and effort the staff has already spent preparing for the appointment.
Accounts that become delinquent may be subject to collection activity, and a $75 late fee may be added to cover the cost of additional handling required. NSF checks will be subject to a $25 fee. No personal checks will be accepted on an initial visit.