As a condition of your treatment by this office, financial arrangements must be made in advance. We depend upon payment from our patients for the costs incurred in their care and the financial responsibility on the part of each patient must be determined before treatment. We will discuss financial options with you before rendering treatment.
By signing the Financial Responsibility Agreement you are agreeing to all of the terms contained in this Consent for Services including the following:
- If you have dental insurance, your estimated portion of payment is due in full at your time of service, unless prior written financial arrangements have been made.
- If you do not have dental insurance, payment for services is due in full at your time f service, unless prior written financial arrangements have been made.
- There is a $35.00 service charge on all returned checks.
- We reserve the right to charge a missed appointment fee for no-shows or cancellations with less than 24-hours notice.
- I understand and agree that any account balance not paid within 90 days must be subject to collection activity. I understand Loza Dental will retain the services of an attorney to assist with the collection of any outstanding balance.
- I understand and agree that I owe an attorney’s fee of an additional 33 1/3 % of the amount I owe to Loza Dental plus 1 1/2 % per month (18% per annum) on the unpaid balance owed, plus court costs on any account not paid within 90 days of the last date of service.
- I understand and agree that, ultimately, I am responsible for payment on my account. As guarantor, I am responsible for any outstanding balances for other family members listed on the same account, due to Loza Dental.