• MM slash DD slash YYYY
  • We are committed to providing you with the best possible care. If you have dental insurance, we are happy to help you receive your maximum allowable benefits. However, due to many changes in insurance policies, it is no longer an easy task to interpret each individual policy. Although we try to stay aware of these changes, it is not always possible. Therefore, we urge you, as the patient, to please check with your insurance company prior to any office procedures. We charge what is reasonable and customary for our area. You are responsible for payment regardless of any insurance company's determination of usual and customary rates. Also, understand that not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will cover. While the filing of insurance claims is a courtesy we extend to our patients, all charges are your responsibility from the date the services are rendered. It is your responsibility to know your individual coverage. Failure to comply with this suggestion could result in you, the patient, being responsible for all costs incurred during your office visit. Please remember that your insurance policy is between you and your insurance company and not between your insurance company and your doctor.

    Payments for services are due at the time services are rendered unless our staff has approved payment arrangements. We accept cash, check, Discover, American Express, MasterCard, or Visa, and offer financing through credit companies.

    We realize that temporary financial problems may affect timely payment of your account. If such problems arise, we encourage you to contact us promptly for assistance in the management of your account.

    We will gladly discuss your proposed treatment and answer any question relating to your insurance. If you have any questions about the above information or any uncertainty regarding insurance coverage, PLEASE, do not hesitate to ask us. We are here to help you.

    I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance on my account for any professional services rendered.

  • I consent to treatment by Fisher Pointe dental for myself and/or minor child. I have been provided the practice's statement regarding use and disclosure of my protected health information. I understand I may have a copy of this statement if I request it from the practice's privacy officer.

    I authorize the release of any information necessary to process my claims and authorize payment to Fisher Pointe Dental.

    Your signature below verifies that you have read and understand this statement, and that all of your questions have been answered.




    The Truth Behind Fluoride