Willing Consent to Financial Agreement
Willing Consent to Financial AgreementDental implants can improve the quality of your life by making your smile more stable, functional and esthetic. I have found that once patients know that they truly desire to improve their smiles, they find the means to afford dental implants and new prosthetic teeth.
Many patients have questions about payment options with regards to dental implants. While many dental offices differ in their policies, there are some similarities to benefit the patient.
The purpose of a financial agreement for dental implants is to provide you a mutual understanding of the method of payment for dental services provided as per your consented Treatment Plan as may include the following:
dated ______________________ totaling $_____________________.
Patient___________________ Date_______________
A dentist may have performed an examination of the condition of my mouth. The dentist has provided me with informed consent information to make a proper decision for treatment of my oral diseased conditions, including no treatment. I have had the opportunity to ask questions and have all of them answered by the dentist and his team. I am willingly taking action to improve my oral health and I am comfortable proceeding with dental health care performed by the dentist — which includes dental services (prosthodontist), dental hygiene services, clinical services, administrative services, laboratory services, prevention services, and education services.
Dental health care is an excellent investment in a person’s medical and psychological well-being. Dental treatment has been shown in scientific studies to decrease the risk of heart disease, stroke, diabetes, cancer, blindness, loss of limbs, and loss of memory such as Alzheimer’s.
Payment options include:
Cash, check, credit cards (MasterCard, Visa, American Express, Discover).
We also work with dental financing companies, Care Credit or Springstone.
_________ Option 1: Payment in full. Treatment over $7,000 paid by check or bank- wire transfer prior to initiating treatment will receive a 3% professional courtesy for administrative simplicity.
_________ Option 2: 50% deposit plus multiple payments as follows:
First deposit of $ _________________________
Balance of $ ________________________ due on ________________________
date
You will be required to sign a credit card authorization form or wire-transfer form to cover costs associated with your dental health care. This information will be held securely and only be used to pay for treatment authorized in advance.
_________ Option 3: Financing Company – Care Credit, Springstone.
You will be required to provide written consent to a Care Credit or Springstone financial agreement.
Late Fees
An effort will be made to keep professional fees to a minimum. Consented treatment fees are expected to be paid – as agreed. Any fees made after the promised date, will incur a late charge of 2% per month (24% annually) until the late balance is paid completely. A $50 processing fee will be incurred for each check that is returned as unpaid.
Hygiene
The dentist has found that if a patient gets their teeth cleaned EVERY THREE MONTHS FOR THE FIRST YEAR by a dental hygienist, their success rate increases. The success is due to the reduction of harmful pathogens stuck on their teeth, gums and bone. It also allows for earlier detection of unhealthy areas, bite problems, loose teeth, food traps, and other problems. I understand that if I choose to not to return for follow-up visits and hygiene with the dentist as recommended, I may be putting my oral health and general health at risk.
In closing…
I hereby agree to comply with the dentist’s recommendations and agree to the terms of this Willing Financial Agreement. Due to the allocated company resources and services such as time, planning, practice, materials, staff, administrative and clinical labor, vendor costs, disinfection and sterilization procedures, surgical supplies, and other expenses —— I understand that no refunds can be offered once treatment has been initiated. Signing this form authorizes the dentist and his team to initiate treatment today.
Patient: _______________________________________ _____________
date
Printed name: _______________________________________
Hygienist: _______________________________________ _____________
date
Dental assistant: _______________________________________ _____________
date
Administrator: _______________________________________ _____________
date
Prosthodontist: _______________________________________ _____________
date
This document is an example of how to prepare your finances while visiting with a dentist or prosthodontist about dental implants, crowns, veneers, bridges or dentures.
For more info about patient forms or payment options, drop us a note.
All the best,
Dr, Joe Kravitz, DDS, MS
Dentist, Prosthodontist, Author, Researcher
Rockville, Maryland
Virginia, Washington, DC
