OFFICE POLICIES

I understand that…

• All patient balances are due immediately after treatment is rendered. Only exception is if a payment plan agreement was put in place prior to the treatment date, in which case 40% down is due at time of treatment.

• If there is dental insurance on the account, I understand that the clinic has established the patient balance based on the information I have provided. And that final treatment payment is subject to the terms and conditions of my insurance provider on the date of service. As such, until payment and/or a response is received from my insurance provider, no patient portion is final.

• Estimates and treatment plans are based upon information gained from the examination. As with any dental treatment, there may be unforeseen treatment adjustments and/or complications. Estimates are preliminary only and lab charges (if applicable) have been estimated and included in the total.

• Estimates do not take into consideration any money that was billed toward my financial maximum or treatment limits that may have been used at other dental clinics or specialist’s offices, as SunRiver Dental does not have access to those claim details and amounts.

• A submission to my insurance provider will be sent to determine an approximate final investment. However, it is an estimate only. Final insurance splits may be adjusted upon receiving the predeterminations. Predeterminations from my insurance provider(s) are NOT a guarantee of payment.

• For the comfort of their patients and team members, that SunRiver Dental is a scent free office

• Any verbal or physical abuse towards the Dentists, team members or patients, will not be tolerated and my result in immediate dismissal from the clinic.

CANCELLATION POLICY

I understand that...

• I have time reserved for my appointment(s) and that SunRiver Dental requires that any changes to appointments are made with a minimum of 2 business days notice. If I do not arrive to the appointment and/or fail to notify the clinic with the required notice, a $125 booking deposit may be required to reschedule. And if I fail to arrive for the rebooked appointment, the deposit will be taken as a fee and not returned.

I declare that I have provided an accurate and complete medical/dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding this medical/dental history, and I consent to my physician being contacted if necessary. I authorize the dentist to perform diagnostic, dental and oral surgery procedures and services including the use of anesthetic as necessary. I also understand that I assume responsibility for any and all fees associated with the procedures and services.