Financial Agreement

Some insurance plans may not cover optional treatment. I hereby accept all
diagnosed procedures listed above for my child or myself. I decided to proceed with the
proposed treatment. I also take financial responsibility for all the additional charges noted
above for optional treatment not covered by my insurance.

Once dental treatment has begun, changes in the anticipated treatment plan may
be required, depending on oral conditions encountered. We will inform you of such
situation, and you will be given the option of continuing or changing treatment.

I acknowledge that options for my dental condition have been fully explained to
me. It is my responsibility to complete treatment and follow recommended preventative
maintenance schedules. If the treatment and preventative maintenance schedules are not
followed, and/or appointments are missed, adverse results could affect my dental health
and dental coverage.

We can estimate what your benefits are, but that is only an estimate. What your
insurance does not cover or pay for, you must pay. Your insurance company provides us
with your coverage eligibility dates. You are financially responsible for any claims that
we bill and your insurance does not cover due to policy termination, employment
changes, cancellation, or any other reason including error. You are mutually responsible
even if you were unaware of the change.

If you choose to discontinue care before treatment is complete, you will receive a
refund in the amount paid, less the cost of treatment received. In addition, a 12%
administrative fee will apply.

For refunds not requested within fifteen (15) calendar days from the date payment
was received, a 12% administrative fee will also apply.

A fee of $35 is charged to patients who miss or cancel 2 appointments in a

calendar year without a 24-hour notice.

A fee of $35 will be charged for returned checks.

In case of default in payment of any sums of money for services rendered, I

hereby agree to pay a reasonable attorney fee and all court costs incurred by the holder in
such action. I hereby waive, to the fullest extent permitted by law, diligence, demand,
protest, notice of protest, and the benefit of any statue of limitation.

_________________________ ______________________________
Patient’s Signature / Date Parent or Guardian Signature/ Date