Please read, fill out, and sign this information sheet for our records. If you have any questions about our payment guidelines, please ask our office manager. Thank you.

Payment Guidelines

  • We request payment in full at the time service is rendered.
  • If you wish to discuss financial arrangements, our office manager will be happy to go over these options with you. All financial arrangements must be made prior to treatment begins, or the entire balance will be due, in full, at the time services are rendered. Multi-visit procedures are due in full at the initial visit when treatment has begun, regardless of how many appointments the treatment takes to complete.

What is your preferred method of payment?

Ο Cash, Check or Debit CardΟ Visa, MC, AMEX, DiscoverΟCare Credit Financing

Important Notice:

Accounts 60 days past due are subject to a finance charge (currently 19.8%) with a minimum charge of $3.00.

We reserve the right to charge for appointments cancelled or broken without advanced notice of at least 24-hours. The charges will be $50 per hour for an appointment with our hygienist, and $100 per hour for an appointment with Dr. Scott Veal.

If an appointment should ever be missed, we will require a credit card to be held on file in order to schedule any future appointment. We reserve the right to charge this card a $25 holding fee for hygiene appointments and 10% of cost of treatment, which will be applied to services rendered at that appointment.

Signature:______Date:______

For our patients with dental benefits:

  • If you have a dental benefit plan, we will file your claims on your behalf as a courtesy to you, and will have your insurance company pay its portion directly to Dr. Scott Veal. We request the estimated portion not covered by your dental benefit plan to be paid by you at the time of service. If your dental benefit plan does not assign benefits to the provider, we ask that you render payment for the services in full, and your plan will reimburse you directly. Please be sure to provide us with your plan booklet so that we may obtain a detailed summary of your plan and help you maximize your benefit. Please remember, your dental benefit plan is a contract between you and the company, not the office, and that you are ultimately responsible for all charges, regardless of their payment.
  • If after 90 days the insurance company has not paid, the balance at this point becomes the patient’s responsibility.

I understand that my insurance is an agreement between me and my insurance company. I also understand that I am responsible for my balance regardless of my insurance. I assign dental benefits to be paid directly to Dr. Scott P. Veal from my insurance company.

Signature:______Date:______