Confidential Dental And Medical History Page 7
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7Financial Arrangements
Payment is due at time of service. Patients with insurance will be expected to pay their “Estimated
Patient Portion” which is calculated based upon the information we receive from the particular insurance
company. is estimated amount will be due on or before the day of service. Any balance due after the
insurance has paid will be billed to the patient and due within thirty (30) days of the statement date.
Appointments involving sedation must be paid in full one (1) week prior to the appointment.
Payment options:
» Cash, Cashier’ s Check, Personal Check
» MasterCard, VISA, Discover, American Express
» Patient Financing - We work with several financial organizations that will allow you to
get the treatment you need now and spread the payments over as much as 60 months,
including “no-interest” programs.
So Everyone Can Have a Healthy and Beautiful Smile Today !
Our mission is to help you to achieve the best possible dental health. Our job is to evaluate the state of
your oral health and then discuss with you our findings and potential treatment options. We will always
give you all of the options that pertain to your condition. Your job is to determine what treatment
option is best for you, and the pace at which you wish to proceed with your treatment. We will gladly
respect your decisions.
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T Y P E N A M E
D AT E
904.262.8409
Bartram Office
Riverside Office
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13241 Bartram Park Blvd.
501 Riverside Ave.,
Bldg. 1700
Suite 104
Jacksonville, FL 32258
Jacksonville, FL 32202
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Parent category: Medical