As a condition of treatment provided by this office, financial arrangements must be made in advance. Our practice relies on timely reimbursement from patients to cover the cost of care. Therefore, financial responsibility must be clearly established prior to treatment.
All emergency dental services, or any services performed without prior financial arrangements, must be paid for in full at the time of service.
Patients with dental insurance understand that all services are charged directly to them, and they are personally responsible for payment. As a courtesy, this office will assist in preparing insurance claims and collecting benefits from insurance companies. Any payments received from insurance will be credited to the patient’s account. However, we cannot guarantee payment by any insurance company and do not provide treatment on the assumption that insurance will cover our fees.
A service charge of 1.5% per month (18% annually) will apply to all balances over 60 days past due, unless other written financial arrangements have been made in advance.
Fee estimates for proposed dental care are valid for six months from the date of the initial examination.
In consideration of the professional services rendered to me, or at my request, I agree to pay the reasonable value of those services to the doctor or their assignee at the time of service, or within five (5) days of billing if credit is extended. I understand that fees will be considered agreed upon unless I submit a written objection within the time allowed for payment. I also agree that the waiver of any term or condition does not constitute a waiver of future terms or conditions. Should legal action become necessary to collect my account, I agree to pay all costs and reasonable attorney fees incurred.
Missed Appointments We respectfully request at least 24 hours’ notice for any appointment cancellation. Missed
appointments without proper notice may be charged at the rate of a standard office visit. Your cooperation helps us provide better care for all patients.
Communication & Information Sharing Consent I authorize Woolf Dental to contact me by phone, voicemail, text, or email regarding my treatment, scheduling, billing, insurance, and other matters related to my care, using the contact information I have provided. I understand that standard message and data rates may apply and that these communications may not be encrypted or secure. I accept this risk and understand I may opt out at any time by notifying the office in writing.
I also authorize the release of relevant information—including insurance details, treatment plans, notes, x-rays, and lab records—to specialists or healthcare providers involved in my treatment for consultation, referral, or case completion.
