Call Us Today! 801-784-4478 | 1747 S. Heritage Ln., Ste. A1, Syracuse, UT 84075
INSURANCE (IF APPLICABLE):
Please check if the patient has a history of the following medical conditions:
Please check if the patient has, or ever had, any of the following habits?
I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.
I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate treatment on the above-named patient.
I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.
Thank you for choosing us as your dental care provider. As part of our service, we try to contain the ever-rising cost of dental care. We are committed to your treatment being successful and to providing the highest quality dental services at a reasonable fee. Please understand that payment of your bill is necessary in order for us to provide your treatment.
We ask that a Patient Information and Health History Form be completed or updated before seeing the dentist to ensure proper treatment and billing. I grant permission to you or your assignee to telephone me at home or at my workplace or any other telephone number listed to discuss matters related to this form. I also agree to allow this office to leave messages concerning appointments and/or results on my answering machine or with a family member.
Patients who carry dental insurance must understand that all services furnished are the responsibility of the patient. Payment for your estimated portion of services is due at the time of each visit which could include co-payments, deductible, percentage or non-covered benefits depending on your insurance plan requirements. As a courtesy to our patients, we prepare and process all insurance forms 3 (three) times. Having insurance does not release the patient from responsibility for services and the patient will be billed for those services until insurance is resolved. If a claim has not been paid within 60 (sixty) days, or the insurance has been billed 3 (three) times and remains unpaid, we ask that you pay the balance using one of the following methods of payment below. A rebilling charge of 1.5% per month will be assessed on any unpaid balance over 60 (sixty) days. Fee estimates are based on our experience with the insurance company and are not a guarantee of the insurance coverage
Our financial policy is designed to give you a number of payment options to choose from in order to make your dental care payment as easy as possible. For your convenience, you may choose any of the following methods of payment:
The adult accompanying a minor and the parent (or guardian) are responsible for full payment. Parents must be present for all dental care authorization to minors.
Please help us serve you better by keeping scheduled appointments. Kindly notify us at least 24 hours in advance if you must cancel or reschedule an appointment. There is a $75.00 charge for all appointments that are broken or missed without a 24-hour cancellation notice.
I understand that I am financially responsible for all charges incurred by my dependents, or myself whether or not covered by insurance. I hereby authorize the office of Heritage Dental Associates to use the following signature for proof of signature on insurance claim forms for assignment of insurance payments and release of information. I agree to pay Heritage Dental Associates for professional services rendered to me at the time of service or according to a payment policy pre-arranged by the office. I agree to pay within 30 (thirty) days of billing, if credit is extended. I expressly agree to pay all costs of collection agency fees assessed at 40% of the total amount due, and all court costs and attorney fees, if these terms are not met.
By submitting this form you agree to the above mentioned consent statement and finiancial policy