Written Financial Policy

Payment Options

You can choose from:

  • Cash, Check, Visa or Mastercard
  • We offer a 10% courtesy discount to patients who pay for their treatment with cash or check prior to or the date services are rendered.1
  • Convenient monthly Payment Plans from CareCredit.2
    • Allow you to pay over time
    • NO annual fees or pre-payment penalties

Please note:

For patients with insurance we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment.3

If you have any questions, please do not hesitate to ask. We are here to help you get the treatment you want or need.





Patient, Parent or Guardian Signature
Patient Name
Date


1Courtesy discount does not apply if insurance is being filed on your behalf.
2Subject to credit approval
3However, if we do not receive payment from your insurance carrier within 60 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier.


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