Alternative text

Office Policy of Payment of Accounts

To avoid misunderstandings concerning payments of accounts, please note that endodontic treatment may not be completed unless payment is received in full on or prior to the last visit.
We will bill your insurance company for you. Your copayment is due at the time of service. You will need to know the following so we can bill your insurance properly:
1) your yearly maximum amount and how much of that amount you have used for the year.
2) your group number, if you have one

You are responsible for all charges that your insurance company does not pay. We will not be held responsible if you exceed your maximum amount for the year and incur additional expense.

If you do not have insurance, your payment is due in part or full on your first visit or the balance is due on your last visit.

Thank you for your kind cooperation. If there are any questions, please ask the receptionist.

Parent or Guardian if patient is a minor
Parent or Guardian if patient is a minor

Tooth Restoration After Endodontic Therapy – Healing Evaluation Visits

It is important to have your tooth restored by your family dentist after completion of endodontic therapy as soon as possible in order to avoid tooth fracture, root canal treatment failure, or unnecessary tooth loss. By signing this form I acknowledge that I assume the responsibility to have my tooth appropriately restored by my dentist.

We will give you a reminder card today to contact our office in 6 months for a check-up radiograph to assess healing. There is no charge for this service. We will do this every 6 months for 2 years to monitor your root canal treatment. It is your responsibility to call for this appointment. A reminder card will be given to you at each subsequent visit. If you have any questions regarding these important examinations, please call the office at (810) 732-7900.

Online Signature×
Draw your signature inside the box Clear