
- Dr. LuAnne M. Curatola
Dr. Joseph A. Zagami
Patient Information Health History
Health History
Please check if you have had any of the following:
Dental History
Smile Analysis
Financial Options and Obligations
We offer a wide range of financial options in order to pay for your dental treatment.
We can receive payment towards your account from any insurance plan in which you can choose your own dentist (PPO,PDO,Premier,etc.). We do this as a courtesy to you, our patient. While we do our best to estimate your "out-of-pocket" expense based up on the information we receive from your plan, we are not resoonsible for any denial or reduction of payment as determined by your insurance. We can never guarantee payment from your insurance. After your dental insurance as paid for dental services rendered, you may have an outstanding balance. This balance may include any deductibles, copayments, denials, and non-covered services. For balance owed, we require a credit card authorization.
FORMS OF PAYMENT ON BALANCE DUE
In order to facilitate access to the very best health care possible, you may choose from any of the following: Cash, Visa, MasterCard, AmericanExpress, Discover, MoneyOrder, Personal Checks, or CareCredit.
FINANCIAL ARRANGEMENTS
Several in-office payment arrangements are available for account balances. All fees will be disclosed to you and financial arrangements discussed and confirmed prior to treatment.
- Pay as You Go: You may choose to pay your obligation with cash, check or creditcard at the time of your visits
- Prepayment in Full: A Prepayment Courtesy will be given for payment in full before or at the first treatment visit (does not include CareCredit payment)
- Split Payment: One half or one third of the total treatment is due at the preparation visit; the second and third payments due in the middle of treatment; and final paymentat the cementation visit of the dental appliance.
- CareCredit: With fast online approval CareCredit can help you get the healthy, radiant smile you've always wanted with the card designed specifically for your dental needs. CareCredit offers No Interest and low monthly payment options, no up-front costs, no prepayment penalties, and no annual fees. CareCredit is a medical/dental line of credit, and can be subject to interest fees as set forth by CareCredit. Pre-approval is required. Go to www.carecredit.com for complete information and pre-approval.
Please Read and Sign the Following:
- I understand that if I become delinquent on my account, my account will be turned over to a collection agency, and I will subsequently be reported to the credit bureaus. In case of total default, I promise to pay any collection costs and attorney fees incurred to collect on this account.
I certify that I have read, fully understand, and accept the above financial policy.