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David Gage DMD205 W FAIRHAVEN AVE STE B BURLINGTON WA, 98233 (360)-757-0651 Written Financial PolicyThank you for choosing David Gage DMD. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options. Dental treatment is an excellent investment in an individual’s medical and psychological well-being. Financial considerations should not be an obstacle to obtaining this important health service. Being sensitive to the fact that people have different needs, we are providing the following payment optionsPayment Options:Our office accepts:-Cash or check, Payment in full at the time of service, we offer a 5% courtesy accounting adjustment for payment upon completion of care-Visa, MasterCardR, American ExpressR, or Discover CardR all accepted here- Special financing options with convenient monthly payments available with the CareCredit healthcare credit card1Allow you to pay over timeNo annual fee3Interest free optionsPlease note:If you choose to discontinue care before treatment is complete, you will receive a refund less the cost of care received. For plans requiring multiple appointments, alternative payment arrangements may be provided. For patients with dental insurance we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment. It is the responsibility of each patient to know the limitations and allowances of their own policy.2David Gage DMD charges $35 for returned checks. If you have any question, please do not hesitate to ask. We are here to help you get the dentistry you want or need. ______________________________________________________________________________________________Patient, Parent or Guardian SignatureDate______________________________________________________________________________________________Patient Name (Please Print)1 CareCredit is a credit card offered by Synchrony Bank and is NOT an in-house credit program offered by David Gage DMD or any other healthcare provider. You may apply for the CareCredit healthcare credit card and if approved, use it at David Gage DMD’s office. However the CareCredit credit card agreement is between you and Synchrony Bank. Subject to credit approval. 2However, if we do not receive payment from your insurance carrier within 30 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier. 3For new accounts: Purchase APR is 26.99%; Minimum Interest Charge is $2. Existing cardholders should see their credit card agreements for their applicable terms. Subject to credit approval. ................
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