Wilkinson Dental

Payment Options Acknowledgement

Wilkinson Dental > Patient Info > Patient Forms > Payment Options Acknowledgement

*Printable Payment Options Acknowledgement

  • *Our mission at Wilkinson Dental is to provide our patients with the highest-quality dental care, therefore, we offer several payment and financing options to help you achieve complete dental treatment and health.

  • PAYMENT OPTIONS:

  • INSURANCE

    Our office is committed to helping you maximize your insurance benefits. We will provide you with a complimentary benefits check to determine your benefits, however, because insurance policies vary, we can only estimate your coverage in good faith but cannot guarantee coverage due to the complexities of insurance contracts. Your estimated patient portion must be paid at the time of service. Should your insurance policy fail to pay or if during the course of treatment your benefits change, you are responsible and accountable for all charges. Our options for taking care of any remaining balance on your dental treatment plan, are as follows:

  • CASH OR CHECK

    Personal checks are accepted. A $25.00 service fee is charged on all returned checks.

  • MASTERCARD / VISA / CARE CREDIT

    We offer low and no interest financing options through Care Credit to help with financing your dental treatment and any out-of-pocket expenses which your insurance does not cover. Care Credit is a third party financing group that provides payment plans for dental services. There is a quick and easy application, and approval can be secured during your appointment. This allows for easy monthly payments (usually without interest). To learn more about Care Credit or to apply, follow this link http://wilkdental.com/about/financial-options/

  • LAYAWAY PAYMENT PLAN

    Save up for your treatment by setting aside funds in preparation for upcoming dental procedures. The Layaway Payment Plan allows patients to make convenient monthly payments over a planned period of time and treatment is scheduled upon payment for the procedure

  • CANCELLATION POLICY:

    Your scheduled appointment time has been reserved specifically for you. We request 24-hour notice if you need to cancel your appointment. Appointment cancelled without 24 hour notice will be subject to a cancellation fee of $25.00

  • INSURANCE PAYMENT POLICY

    I authorize and request my insurance company to pay directly to the Dentist benefits, if any, otherwise payable to me. I understand that my dental insurance may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I agree to pay collection fees including attorney fees and court costs if any delinquent balance is placed for collection or suit.

  • PAYMENT POLICY:

    PAYMENT FOR TREATMENT IS DUE AT TIME OF SERVICE.

  • I have read and understand all payment and cancellation policies,

  • By filling in this section you are agreeing that you have read and understand all payment and cancellation policies. *Name of parent/legal guardian, if minor
  • If parent or legal guardian
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY