PAYING FOR YOUR DENTAL TREATMENT

Thank you for choosing Brilliant Smiles Family Dentistry PLLC. We believe that every patient has the right to expect the very best professional care we can provide. In turn, we feel we can expect your cooperation in following our payment policy. After a thorough examination, you will be given a treatment plan and estimate of the cost required to restore your oral health.
If you are fortunate enough to have dental insurance to assist you with your treatment, we will approximate the amount that your insurance company should pay and ask that you pay the remaining balance. Regardless, if you have insurance or not, the total fee will be your responsibility. It is important to keep us informed of any and all insurance changed, as it is your responsibility to provide us with that information. If we are not given correct or sufficient information, you are responsible for payment of your dental treatment.

PAYMENT OPTIONS

Convenient monthly payment plans from Care Credit*
  • Allows you to pay over time
  • No annual fees or pre-payment penalties

ADDITIONAL INFORMATION

Brilliant Smiles Family Dentistry PLLC charges $25 for returned checks.
If for any reason your dental insurance company does not pay as much as anticipated, you will be expected to pay the difference upon receipt of your statement.
There is a 1.5% finance charge on all accounts over 30 days which is an annual finance charge of 18%

Patient, Parent or Guardian Signature

Date
*Subject to credit approval