Home/Patient Info/New Patient Forms/Financial PolicyFinancial Policy It all starts with a smile... pass it on!First Name(Required) Last Name(Required) Who is responsible for your out-of-pocket dental expenses? Self Other Name of responsible party Social Security # of person financially responsible Email address to send statements(Required) Please list any other family members that the above person is financially responsible forFill full name of family member 1 Add another family member? 1 Yes No Fill full name of family member 2 Add another family member? 2 Yes No Fill full name of family member 3 Add another family member? 3 Yes No Fill full name of family member 4 Add another family member? 4 Yes No Fill full name of family member 5 If you have Dental Insurance, please answer the following questions:Name of person that carries the Dental Insurance This person’s date of birth This person’s Social Security # This person’s Insurance ID # This person’s employer Name of Insurance Company Insurance Company’s phone # Insurance Plan’s group # Please upload photos of your insurance card (font and back) Drop files here or Select files Max. file size: 2 GB. In an effort to prevent any misunderstanding, we have set forth this financial policy. Full payment is expected at this time of service unless other arrangements are made. When major services that involve lab work are performed (i.e. crowns, onlays, dentures, etc.), 50% is due upon preparation, and the balance is due upon insert. A service charge of 1.5% per month on the unpaid balance will be charged after 30 days. If an appointment is broken or cancelled with less than 24 hours notice, a charge of $50.00 will be applied to your account. Returned checks are subject to a $20.00 service charge. 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.By signing below, I attest that to the best of my knowledge, the information provided is true and accurate. I understand and accept the financial agreement as set forth above.Print name Signature3592 Monroe Avenue, Pittsford, New York 14534 (585) 248-5250 PhoneThis field is for validation purposes and should be left unchanged. Δ