RESPONSIBLE PARTY INFORMATION

(holder of insurance)

FINANCIAL POLICY
Your child’s estimated share of cost is due and payable on the day the treatment is performed. Understand that dental insurance usually covers only part of the fees for services based on your specific dental benefit underwriting. We do our best to provide you with an estimate accordingly. Please understand that the contract for dental insurance is between you and your insurance company and not our practice. Any disputes of coverage need to be handled through the insurance company directly by you and you accept personal financial responsibility for services provided. Your signature here authorizes assignment of benefits to us so we can submit claims.
To avoid missed appointment charges we request that you inform us of cancelation notice 48 hours prior to the appointment, so that we can offer the appointment to another child. If you have 2 broken appointments, you will be automatically charged $50.00 for your missed appointments. A broken appointment is considered a “no show” or cancelling an appointment the same day. The signature of the responsible party / Legal Guardian below authorizes Dr. J Shahangian or qualified assignee to complete an oral evaluation including but not limited to examination, cleaning, fluoride and/or diagnostic X-rays as indicated to evaluate oral health.