Patient Office Policy Form

We ask that you make every effort to keep your appointments. This appointment time has been set aside for you; missing it will disrupt proper sequencing of your care and delay completion of your treatment. Our office utilizes a confirmation system that will contact you before your appointment by email, text, or phone call. We ask that you please confirm your appointment via this system so we can adequately prepare for your appointment. If you miss this confirmation call, please call our office at (616) 534-0080 to confirm your appointment. We ask that you call at least 24 hours before your appointment if you need to cancel or reschedule. Failure to call 24 hours before will result in a broken appointment fee. We understand that family emergencies or sudden illnesses do arise, but please call the office to reschedule if this happens. After three (3) broken or missed appointments, you will be dismissed from our practice.

Payment is due at time of service. Our office accepts cash, personal checks, Master Card, Visa, Discover, American Express, and Care Credit. Accounts aging past sixty (60) days will accrue billing fees.

As a courtesy to you, we will help you process all of your dental insurance claims. Insurance coverage is subject to eliminations, exclusions, waiting periods, frequencies, age restrictions, deductibles, and maximums. It is your responsibility to be familiar with your dental plan. You may need to contact your insurance company to obtain your dental plan benefit information. We will provide you with an insurance estimate. This however is not a guarantee that your insurance will pay the exact amount estimated. Your benefits may differ due to a number of reasons as stated above. Your insurance company and your plan benefits ultimately determine the amount paid. Our office is committed to providing the best treatment for our patients. All charges you incur will be your responsibility, regardless of what your insurance covers. We must emphasize that as your dental care provider our relationship is with you, our patient, not your insurance company. We encourage you to be up to date with your coverage.

We ask that you please read and sign this letter as confirmation that you understand our office expectations. You will be given a copy to keep for future reference.

Thank you for coming to our office. We look forward to getting to know you and your family.

Sincerely,

Dr. Sarah Palmer, Dr. Amy Harmon, and staff