Financial Policy

I authorize and request dental treatment/services for myself and/or my dependent(s). I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate. I understand that the treatment plan and fees proposed are subject to modification depending upon unforeseen or undiagnosed conditions that may be recognized only during the course of treatment.

I authorize the dentist to release any information, including the diagnosis and records of treatment or examination for myself and my dependent(s), to payors and/or healthcare practitioners involved in my/my dependent(s) care. I understand that I am responsible for any financial obligation incurred for the dental treatment/services provided.

I agree to pay my account with Stewartville Family Dentistry in full and in a timely manner, and that if I fail to do so, I agree to be liable to Stewartville Family Dentistry for interest (at the rate of 6% per annum on balances due more than 60 days), court costs, expenses, attorney fees, and other necessary costs incurred to enforce payment of any part of said accounts.

If you have dental insurance coverage, we would be happy to complete your claim form and submit it for you.

You are at all times responsible for payment of your account regardless of insurance payments.