Govind Hariharan D.M.D., M.S.

5024 N.Jupiter Rd.Garland, TX 75044

Ph: 972) 414-6432

Financial Policy For Our Dental Patients

Our goal is to provide the best dental care for you while avoiding any confusion regarding our financial policy. Our office will provide you with the amount of payment that will be required to treat your case in advance of all the procedures. This will allow you to discuss treatment alternatives or payment arrangements if finances are a concern.

DISCOUNTS

  1. Patients who pre-pay or pay at the time of treatment the total fee for treatment will receive a 5% discount with cash payment only. This does not include hygiene appointments
  2. Senior citizens (over 65 years) will receive a discount of 10% when payment is made in full at the time of treatment. This does not include hygiene appointments. (Cash)

REGARDING FINANCIAL ASSISTANCE

We do realize that financial circumstances, on occasion, can make payment difficult. If you have a financial concern we encourage you to speak to our financial coordinator. We also accept Visa, Master Card, American Express and Discover. We also work with financing companies that can help you with payment plans.

CANCELLATION, RESCHEDULING & NO SHOWS

We reserve time for our dental patients so we can give each patient the time and attention that they deserve. We ask you to notify our office 48 hours in advance if you require to change your appointment. Failure to comply will result in a $40.00 missed appointment fee.

FINANCIAL RESPOSIBILITY AGREEMENT

The agreement of treatment and payment is between the patient and our office. Insurance is accepted on assignment but the patient must pay the estimated portion (including deductible) at the time of treatment. Patient is responsible for any portion that the insurance does not cover.In the event of non payment the patient agrees to pay all the cost of cancellations, including but not limited to attorney fees, court costs, collection agency fees and all other fees involved. If a check is dishonored or returned you agree to cover any returned check fees placed on this office. Your usage of a check for payment is your acceptance of this agreement and its terms.

I have read and understood the financial policy of this agreement and I agree to its terms. I also understand and agree that such terms may be amended from time to time by the dental office

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Patient/Responsible Party Date