Alternative text


I (or authorized representative/guardian) hereby authorize Costa Family and Cosmetic Dentistry to take x-rays, study models, photographs and/or any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the patient’s dental needs. Upon such diagnosis, I authorize Costa Family and Cosmetic Dentistry to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital on any possible complication.


We are committed to providing you with the best possible dental care. In order to begin a long lasting professional relationship, we ask for your understanding of and cooperation with our financial policies.

We ask that you realize that we don’t work for an insurance company. Rather we work 100% for our patients. We feel that insurance can be a great benefit for many patients and want you to know we will do everything in our power to ensure you get every benefit allotted in your insurance contract. However, the treatment we recommend and the fees we charge will always be based on your individual needs, not your insurance coverage.

We will submit your claims and receive corresponding payments. You will be responsible for making any estimated co-payments in full at the time of service. We will be happy to submit your insurance and collect payment from them provided we have verified eligibility. Any remaining balance after the insurance payment has been received will be due upon receipt of statement.

Financial alternatives for extensive dental treatment can be discussed and approved by our financial coordinator. These alternatives are not to be considered permanent arrangements.

Financial alternatives for extensive dental treatment can be discussed and approved by our financial
coordinator. These alternatives are not to be considered permanent arrangements.


1) When appropriate, we will be happy to submit a pre-treatment estimate to your insurance at your request after you have provided appropriate insurance information.

2) Accounts exceeding 90 days since the last payment will be reviewed for collection by a third party. If you receive a statement you do not understand, please call us immediately. DO NOT IGNORE the statement. Communication is key to our relationship.

3) If an account requires collection by a third party, all attempts to collect your debt will be done by the collection agency. We sincerely hope these measures will never become necessary

4) Unpaid insurance claims exceeding 90 days or after multiple attempts to file with the insurance carrier will become the patient's responsibility and you will be required to pay the balance in full.

5) As of January 1, 2009, we no longer submit secondary insurance. We will provide you with the proper information but it is the patient's responsibility.

6) A $75 (per hour) fee will be charged to your account for each missed appointment and appointments cancelled within 48 business hours. Appointments that are scheduled for more than one hour will be charged at a rate of $75 per hour. We appreciate your respect for other patients who can utilize your reserved time and your respect for our time. We extend the same courtesy.

7) Prosthetic cases (crown, bridge, veneers, etc.) as well as Invisalign® and cosmetic bleaching will not be delivered until final payment has been received or financial arrangements are on file.

8) There will be a $25 charge for all returned checks, payable by cash or credit card only. Checks which are not rectified immediately will be surrendered to a third-party collector for legal action.

If you have any questions concerning the above information, please do not hesitate to ask. We are here to help you!

I have read and understand the above information.

Online Signature×
Draw your signature inside the box Clear