blanks* As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. All dental and surgical procedures are to be paid in full at the time of service. All sedation (anxiolysis) appointments require a 1 week cancellation notice. You will need to make a pre-treatment appointment at least 1 week prior to your sedated treatment appointment to receive your prescriptions, pre-op and post-op instructions, sign consents, and make your payment for treatment. This appointment is mandatory. It is not ethical for us to have you sign consents or take money from you on the day of your sedated treatment appointment because when you arrive to our office you will already have sedation medication in your body. This appointment should take 30 minutes. There is no charge for this visit.
Insured Patients: You are financially responsible for any and all charges at Palm Desert Dentist office. No matter what your insurance pays.

blanks* This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. You are responsible for payment in full. Any insurance benefits quoted are estimated: your actual indemnity may be less. If we are a contracted provider with your insurance we will accept your copayment at time of service. You are responsible for all amounts not covered by your insurance. If we are NOT contracted with your insurance company, you will pay for treatment in full and your insurance will reimburse you directly. For all patients with insurance; we will submit claims and all necessary documentation as required by your insurance company as a courtesy to you, but all payment responsibility lies with the patient. Understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.
Any balance remaining on an account for over 30 days will be charged a finance charge of 18%. We offer a 5% prepayment courtesy if you pay with cash or check for treatment plans that are over $5000.00 when you pay for the complete treatment plan at your pre-treatment appointment.

blanks* By signing below I acknowledge that I am here for treatment of my own free will and request my choice of treatment be done to correct the dental conditions that I have presented to Palm Desert Dentist. In consideration for the professional services rendered to me, or at my request by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered. I further agree that the reasonable value said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to all costs and reasonable attorney fees if suit were instituted hereunder.
I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form and treatment and payment and agree to their content.

blanks* Should the need arise,