Sky Periodontics & Implant Dentistry

5422 Hwy 6, Ste 101
Missouri City, TX 77459 info@skyperioimplants.com (281) 205-4019

Financial Policy Form

For my convenience, this office may release my information to my insurance company, and receive payment directly from them.

I understand that if I begin major treatment that involves lab work, I will be responsible for the fee at that time.

If sent to collections, I agree to pay all related fees and court costs.

Every effort will be made to help me with my insurance, but if they do not pay as expected, I will still be responsible.

I agree to pay finance charges of 1.5% per month (18% APR) on any balance 90 days past due.

I will pay a fee for appointments broken without 24 hours notice.

Treatment plans may change, and I will be responsible for the work actually done. I agree to let this office run a credit report. If no, then all fees are due at time of service.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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