Gentle Dental Guidelines

    We would like to take this opportunity to thank you for being an important member of our dental family, and assure you of our continued commitment to excellence. The following is a statement of our Financial Policy, which we require you read and sign prior to any treatment.

    Payment Options
    In order to keep our fees from increasing considerably and to minimize the expense of billing and accounting, we have chosen to offer our patients several financial options.

    1. Payment at time of treatment by cash, check or credit card.
    2. Prepayment of a selected treatment plan to receive a 5% courtesy.
    3. In-office finance plans that offer interest free loans or extended payment plans on approved credit.

    Regarding Insurance
    If you have dental insurance, we will accept assignment directly from your primary insurance company if you agree to the following terms:

    • I am responsible for the payment of all treatment fees on my account.

    • I am responsible for the estimated portion not paid by the insurance company at each visit.

    • If upon payment by the insurance company, there is a remaining balance, I am responsible for the amount in full at that time.

    • If my insurance company fails to make payment within 90 days, I will be responsible for the amount in full at that time.

    Please be aware that some of the services provided may not be covered or may be reduced to an alternate benefit under your insurance plan. For example, most insurance companies will reduce their benefit for composite (white) fillings to the benefit for an amalgam (silver) filling. This will result in a higher out of pocket expense, as our office does not perform amalgam fillings.

    **Our office does not accept assignment from secondary insurance.**

    Usual and Customary Rates
    Our practice is committed to providing the best treatment for our patients. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.

    Minor Patients
    The adult accompanying a minor and the parents (or guardians of the minor) is responsible for full payment.

    Missed Appointments
    Unless cancelled, at least 48 hours in advance, we reserve the right to charge $50.00 - $100.00 per hour for a missed appointment. Please help us serve you better by keeping scheduled appointments.

    We appreciate your concern in our need to enforce these guidelines in order to deliver to you, our valued patient, continued optimum care. Please let us know if you have questions or concerns.

    I have read the Financial Guidelines. I understand and agree to these terms.