It all starts with a smile... pass it on!

Office Financial Policy

In an effort to prevent any misunderstanding, we have set forth this financial policy.

  1. Full payment is expected at this time of service unless other arrangements are made.
  2. When major services that involve lab work are performed (i.e. crowns, onlays, dentures, etc.), 50 percent is due upon preparation, and the balance is due upon insert.
  3. A Service charge of 1.5 percent per month on the unpaid balance will be charged after 30 days.
  4. If an appointment is broken or cancelled with less than 24 hours notice, a charge of $25.00 will be applied to your account.
  5. Returned checks are subject to a $20.00 service charge.
  6. It is understood and agreed that in the event that any outstanding balance has to be referred to a collection agent or attorney for recovery, the patient will be fully responsible for any costs, including but not limited to attorney's fees.

Please fill out the following information of you have Dental Insurance

(Make sure that all information is complete. It will greatly expedite the processing of your claim. Thank You.)

**Please print name and sign below to indicate that you have read and fully understood said policy**

3592 Monroe Avenue, Pittsford, New York 14534 (585) 248-5250

To learn more about what makes our team and practice so unique, or to schedule your first appointment, get in touch with Pittsford Family Dental and a member of our staff will be happy to get you started.

We can be reached by phone at 585-248-5250 or via email through our contact page.

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