Office and Financial Information Form in San Diego, CA

Welcome to our office. Our goal is to provide each patient with comprehensive quality dental treatment in a friendly, healthy and caring manner, utilizing the most current techniques and technologies, to respond fully to your individual needs and preferences.
We regard your complete understanding of your financial responsibilities as an essential element of your dental care. If you have questions, please discuss them with our office manager. For your convenience, we accept cash, checks, Master Card, Visa, Discover, and Care Credit. We offer a 5% courtesy discount when fees are paid in full at the time of scheduling.
As a courtesy to our insured patients, we will gladly file your dental claims for services rendered, and we will do our best to get your insurance to pay for these services. Please understand that we are only able to give you an estimate for your dental care. After your insurance pays its portion there may still be an amount due. This amount will be your responsibility and will be sent to you in the form of a statement. If after 60 days there has been no insurance payment made, it is your responsibility to follow up with your insurance company and attain payment.
I assign all insurance benefits, if any, to be paid to the doctor, and I understand that insurance coverage is solely a benefit and that treatment is provided to the patient, not to the insurance company. I understand that the insurance company is responsible to the patient and the patient is responsible to the doctor for professional care.
Initial
I authorize the doctor to perform appropriate therapeutic and diagnostic procedures, such as examinations, x-rays, periodontal charting, study models, etc., in order to make a thorough diagnostic of the patient’s dental needs. I understand that some of these procedures may not be covered by insurance, but are necessary for proper diagnosis and treatment. I will be informed of fees prior to receiving services.
Initial
I understand that this office does not use silver amalgam fillings for restoring teeth. I am aware that by selecting this office, I am choosing not to have silver amalgam fillings, and I understand that some insurance companies and dental plans do not cover alternative restorations (resin-white fillings) and I will be responsible if there is any cost difference.
Initial
I understand that payment for dental services is entirely my responsibility and is due and payable at the time of services, unless financial arrangements have been made in advance. I will be informed of fees for services prior to receiving treatment.
Initial
SCHEDULED APPOINTMENTS
We request that our patients call our office at least 48 hours prior to the scheduled time to cancel or change and appointment. Appointments that are cancelled or changed with less than 48 hours notice are considered a Broken Appointment and may be subject to a cancellation fee.
Initial
Major appointments, such as crown and bridge, cosmetics, root canal treatment, and periodontal treatment, etc., may require a deposit to reserve the doctor’s time. I understand that this deposit is non-refundable unless 7 days notice is given prior to the appointment.
Initial
I have read and understand the financial and appointment policy and agree to abide by its terms.
PATIENT SIGNATURE/RESPONSIBLE PARTY SIGNATURE*
Date*
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SCHEDULED APPOINTMENTS