Dear Patient,

Before proceeding with any dental procedure at our practice, we want to ensure that you have a clear understanding of the financial aspects involved. This financial consent statement is intended to outline the responsibilities and expectations related to the costs associated with your dental treatment. We kindly request that you carefully read and acknowledge this statement before we commence any dental procedures.

1. Cost Estimation: We will provide you with a detailed estimate of the anticipated costs associated with your dental treatment plan. This estimate will include the fees for each procedure, as well as any applicable taxes or additional charges.
2. Insurance Coverage: If you have dental insurance, we will assist you in determining your coverage and estimating the portion that may be reimbursed by your insurance provider. However, please note that any coverage or reimbursement provided by your insurance company is subject to their policies and limitations.
3. Patient Responsibility: As the patient, you are responsible for the payment of all dental services received. This includes any remaining balance after insurance reimbursement (if applicable) and any deductible or co-payment required by your insurance plan.
4. Payment Options: Our practice accepts various payment methods, including cash, personal checks, credit cards, and dental financing plans (if available). Please discuss your preferred payment option with our staff prior to the commencement of your treatment.
5. Treatment Plan Modifications: During the course of your dental treatment, it is possible that modifications or additional procedures may be necessary. In such cases, we will inform you of any changes in the treatment plan and discuss the associated costs before proceeding.
6. Missed Appointments and Cancellation Policy: We kindly request at least 24 hours’ notice if you need to cancel or reschedule your appointment. Failure to provide adequate notice or repeated missed appointments may result in additional charges or loss of deposit.
7. Delinquent Accounts: Any outstanding balances not paid within the agreed-upon timeframe may be subject to late payment fees or collection actions. We encourage open communication regarding financial concerns to avoid such situations.