Insurance and Appointment Agreement

Name*

Date of Birth*

I*

wish to assign my dental benefits to Singer Dental and I understand that any amounts that are not covered by my benefits are my sole responsibility. I may alternatively select to pay for my treatment directly and have benefits assigned directly to me.*

I acknowledge that if I want to be certain of coverage I will contact my benefit provider personally for the coverage breakdown in detail and attain a pre-determination for all specific anticipated procedures.*

I acknowledge my care provider (Dentists and Hygienists) at Singer Dental may recommend treatment for my dental health that is not a covered benefit under the specific plan selected by my employer. I will advise when booking valuable chair time if I intend to decline recommended services.*

I acknowledge that my benefit co-pay (the amount I pay) at the time of booking or at the appointment is an estimate only. I may have a remaining balance to settle personally after my provider processes payment, or I may have a credit to apply to future treatment.*

I acknowledge that in order to avoid a cancellation fee or forfeit my booking fee, I will provide two working days’ notice if an appointment time is no longer feasible. If my personal or work schedule is unpredictable, I will be provided with Same Day Privilege booking options.*

I am providing my credit card information below, and I authorize Singer Dental to charge anyoutstanding balance that I have on my account.*

Card type*

Card #*

Expiration*

Cvv*

Date*

I*

have read and understand the above agreement*

Insurance and Appointment Agreement

Insurance and Appointment Agreement

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