Cancellation Policy Form

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Cancellation Policy

Restorative and Hygiene Appointments

We ask for at least 2 business days advance notice for canceling or rescheduling an appointment; otherwise a fee of $100 per hour scheduled will be assessed to your account.

Note: All cancellation fees must be paid prior to scheduling subsequent appointments.

The treatment that is planned for you is specific to you. It is important for you to keep the scheduled date and times to properly complete your treatment.

A broken appointment is a loss to three people --- the patient who missed the valuable time, the patient who could have taken the valuable time; and the doctor who was fully staffed and prepared for the appointment.

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Acknowledgement and Release

Insurance

We provide services for our patients with the understanding that they are responsible for payment in accordance with our financial policy. Upon your request, we will prepare and submit insurance claims and reports to assist you in obtaining maximum benefits available; however, Dr. Segulyev's treatment recommendations and fees are not affected by the presence or absences of insurance benefits. Treatment recommendations are based on your dental needs and desires and are not a reflection of your dental benefits. Your dental benefits are a contract between you, your employer, and the insurance company; therefore, we do not confirm insurance eligibility or predetermine recommended treatment.

Collections

In the event the balance becomes more than 60 days overdue, billing may be turned over to an outside collection agency. The responsible party listed above agrees to pay interest, collection and other legal expenses related to collection of fees owed. Waiver of any breach of any time or condition shall not constitute a waiver of any further term condition.

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