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3Go Dental Financial Policy
Thank you for choosing GO Dental for your dental needs. This form is to outline our policy in regards to
accepting your insurance to pay us directly.
Insurance (excluding Social Services and Indian Affairs)
As a courtesy, our office will accept payment from your insurance company directly. We require 20% - 30% at
the time of your appointment to cover the amount your insurance does not pay. If you prefer not to pay the
20% - 30%, we will require a valid credit card to have (securely) on file so that we can charge the difference
once insurance does pay for your treatment. You will only be notified before charges are put through if they
are over $150. Any amount not paid by your insurance is due within 30 days.
Ultimately, it is your responsibility to be aware of your dental coverage and also please be aware that some
services we provide may not be covered by your insurance.
Cardholder Information
Credit Card #: __________________________________________ Expiry Date: _____________
Full Name on Card: _____________________________________________________________
Signature: _____________________________________________________________________
Personal Cheques
We do not accept personal Cheques.
Missed and Short Notice Cancellations (All patients)
At GO Dental, we require a minimum of 24 hours’ notice to change or cancel an appointment. There will be a
$75 charge per appointment if missed or cancelled with insufficient notice. _______ INITIAL
Pre-Determination Policy (All Patients)
Many insurance companies require authorization for specific procedures in advance. In most cases, we can
begin treatment before receiving an authorization. However, patients need to understand that if they decide
to go ahead with treatment without a pre-determination, they will be responsible for the cost of treatment
should their insurance not pay. _______ INITIAL
_________________________
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DATE
PRINT NAME
SIGNATURE
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