Online Financial Agreement

Mountain View


Our goal at Pioneer Dental Group is to provide our patients with the highest quality dental care possible while utilizing the highest quality materials, technology, and education tools available. Our financial policy is intended to facilitate excellent service while minimizing our administrative costs.

Our office strives to give our patients the most accurate estimate of their dental investment as possible and does expect full payment at the time of service. All charges you incur are your responsibility regardless of your insurance. As your dental care provider our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employers, and the insurance company. Our office is not a part of that contract. If payment from your insurance company has not been received within 60 days of the date of service you will be expected to pay the balance in full.

As a courtesy, our office will help to process all of your insurance claims. By signing below, you are authorizing your insurance company to pay your benefits directly to our office. In order for our office to file your insurance claims, you must bring a completed dental insurance form or proof of insurance at each appointment.

Our office accepts cash, personal checks, Mastercard, Visa, Discover, American Express, and offers payment plans through third party financing. If you would like more information regarding the third party financing please check with the financial coordinator.

Returned checks and balances older than 60 days may be subject to collection fees and finance charges at the rate of 1.5% per month. (18% annually)

Our office scheduled your dental appointments carefully. Time, trained personnel and dental equipment are reserved for each procedure so we request that you give our office 48 hours’ notice if you need to cancel or reschedule your appointment. Cancellations are not taken via e-mail or voice mail. Missed appointments or late cancellations can be subjected to a $50.00 fee. There will be a $30 duplication fee applied for any unpaid radiographs should they be requested.

Pioneer Dental Group is committed to providing you with the best experience in dental care so please do not hesitate to ask if you have any questions regarding our financial agreement.

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Signature of Patient or Responsible Party


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