Insurance and Appointment

Javascript is disabled

Javascript is disabled on your browser. Please enable it in order to use this form.

Page 1

Insurance and Appointment Agreement

First Name*

First Name

Last Name*

Last 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.*

initial here

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.*

initial here

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 benefit provider processes payment, or I may have a credit to apply to future treatment.*

initial here

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.*

initial here

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

initial here

Card type*

Card #*

Expiration*

Cvv*

Date *

I have read and understand the above agreement.

Signature

Your form has been submitted

Thank you for submitting the application. One of our office staff will reach out to you shortly.

Server Side Error

We faced problems while connecting to the server or receiving data from the server. Please wait for a few seconds and try again.

If the problem persists, then check your internet connectivity. If all other sites open fine, then please contact the administrator of this website with the following information.

TextStatus: undefined
HTTP Error: undefined

Processing your request

Error

Some error has occured.