Thank you for choosing Dentistry at 1818 Market Street! Our primary mission is to deliver quality comprehensive dental care in a calming, friendly environment.

Please take a moment to review our office's financial and appointment policies.

• We participate with most Dental Preferred Provider Organization (PPO) insurance plans. We will verify your benefits and submit to your insurance carrier as a courtesy; however it is the patient's responsibility to know their individual benefits (including limitations) and to pay for any services not covered by the insurance plan.
• Patient copayments or payments for services not covered by insurance are due at the time of service. In the case of extensive treatment plans, payment arrangements can be made, but must be in place prior to treatment being rendered.
• For your convenience, we do accept Visa, Mastercard, American Express, Discover, as well as cash, personal check or Care Credit (an independent financing company).
• Flexible Spending Accounts/RSA Cards are treated as standard credit cards. It is the patient's responsibility to request/provide documentation for reimbursement.
• We require 24 hour notice in regards to changes or cancellation of appointments. Appointments cancelled within 24 hours, or broken appointments will be subject to a $75.00 fee. In addition a 10 minute grace period is given for all appointments. If later than 10 minutes, the appointment will be rescheduled.
• Retunred checks are subject to fee of $25.00

We hope that this will serve to clarify our policies and invite you to ask our staff any questions you may have. Accepting the terms in this form states that you are aware and compliant with all policies set forth by our office. We look forward to providing all your dental needs.

I grant permission and consent to Dentistry at 1818 Market Street to use photographs of my procedures or treatments including but not limited to: publicity, copyright purposes, illustrations, advertising, and web content.