Payments Options: Cash/Check/Visa/MasterCard/Amex/Discover/Care Credit
Past Due Accounts: Account aging begins the day your charges are incurred. Accounts that are ninety days past due may be turned over to a third-party collection agency. Should it become necessary to place your account for Collections, and/or Small Claims Court, you shall be responsible to pay all costs thereof including, but not limited to, attorney fees. We dislike doing this and will do so only if all other efforts to collect your unpaid balance have failed. Once an account is turned over to collections, we will provide emergency referral for a period of 30 days.
Cancellations: Our goal is to have a relationship of trust and respect with our patients. We require a 48-hr. notice to cancel an appointment. Habitual “NO SHOWS” or “CANCELLATIONS” may result in the ability to schedule future appointments. Please mark your reserved appointment day and time on your calendar. We look forward to seeing you.
Minors: The adult accompanying a minor is responsible for full payment of services. Please do not leave children unattended. Divorce decrees are between the two consenting adults, and we are not responsible for separate billing.
Mystic Dental Group reserves the right to update and make changes to the above stated policies at any time without prior notification.
By signing this form, I verify that I completely understand, agree, and accept the policies outlined above. I further acknowledge that I am responsible for all dental services rendered for me and my dependents (if applicable).