Financial Policy

Please list any other family members that the above person is financially responsible for

If you have Dental Insurance, please answer the following questions:

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% is due upon preparation, and the balance is due upon insert.
3. A service charge of 1.5% 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.

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.

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