Office Policies

Ultima Dental Wellness is hereby authorized to maintain the “Patient(s)” financial information in its records in order to make arrangements for payment of dental services from the Patient’s benefits provider(s). Ultima Dental accepts the assignment (direct billing) of dental benefits for the Patient’s convenience. If you request direct billing to your dental plan, a valid credit card is required to be left on file. This card will also be charged for any unforeseen balance not collected at the time of the visit and not paid by your dental benefits plan. Ultima Dental agrees not to disclose credit card information to third parties or to use credit card information unless authorized by the Patient to do so. The patient hereby agrees that amounts owing after payment of insurance benefits will be charged to the Patient’s credit card unless alternative arrangements are made and agreed to by both Parties.

With regard to dental health benefit plans, it should be realized that the plan is between the benefits company and the employee (i.e. patient) and as such the details of coverage are unknown to Ultima Dental. Ultima Dental will attempt to estimate the cost of the proposed treatment as accurately as possible. However, in the event of a discrepancy between the estimated cost and the actual cost of the treatment, the difference will be the responsibility of the account holder.

CANCELLATION POLICY

If it becomes necessary to cancel an appointment, I understand that 48 hours notice is required for cancellation of that appointment. There will be a $75 per hour fee for missed or no-show appointments which will immediately be charged to my credit card on file without further notice.

Patient Name