Forms and Policies | Discovery Pediatric Dentistry

Office Forms

For your convenience and to save time at the first appointment, you may download, review, and complete the following forms. Please bring the completed forms with you to the office.

Other Forms Available

Appointment Policies

Please call us at (415) 441-7766 to make an appointment.

No charge will be made for rescheduling your appointment if a 48 hour notice is given to us so that your child's reserved time can be given to another patient. We do not consider a message left on or with the answering service as a 48 hour notice. You need to contact our office and speak with one of our reception staff during normal business hours.

Every effort will be made to be on time for your child's appointment. However, no one can predict a child's behavior at any one appointment so there may be times that our office will be running behind time. We will sometimes need to rearrange our schedule in order to accommodate a child who has been injured or had an accident.

Please accept our apologies ahead of time should such a delay occur during your child's appointment. Please understand that we will do exactly the same if your child is ever in need of emergency care.

A pediatric dental office just has to run on "Children's Time" sometimes!

Fees

Our fees are based on the actual work provided for your child.
Payment is required at each appointment as services are rendered and can be made by cash, check, American Express, VISA, or MasterCard.
Please be aware that whichever parent brings your child to our office is legally responsible for payment of all fees.
We cannot send statements to other people.

Charges

Charges may be assessed for the following:

Broken Appointment: $35 - $50 - $75 - $100 - $150
Late Cancellation (less than 48 hours): $35 - $50 - $75 - $100
Returned Check: $25 + $5 (bank fee) + returned check amount
Minimum Late Charge (for any outstanding balance): $25 per month

Payment Options

We accept most dental insurance plans & credit cards
Interest free patient financing (Care Credit)

Financial Policy

Payment is expected in full at the time services are provided for your child. When this is not possible, Financial Arrangements must be made prior to treatment. Any previous Past Due Family Account Balance must be cleared prior to scheduling any future appointments.

Dental Insurance

We are not influenced by third parties such as insurance companies when determining the best course of treatment for your child. We coordinate your insurance benefits with your child's treatment plan and will help to maximize all insurance benefits that you have. As a convenience to you, our staff will assist you by processing your claims.

Families with dental insurance will be asked to provide insurance information such as your employer's name, insurance carrier, group number, insured's name and birth date, and dependent's names and birth dates etc when you call to make your appointment. From the information that you provide, our staff will verify your insurance eligibility and benefits as best we can before you arrive. Our staff will advise you of the estimated co-payment for the first visit and will complete a written Financial Arrangement for any treatment needed after your child's examination has been completed. You will be required to pay your estimated co-payment portion the day that services are provided for your child.

Please remember that professional services are rendered and charged to the patient and not to the insurance company. Insurance reimbursement is a contract between you and your carrier. If your insurance carrier does not pay within 60 days, our office shall expect payment in full from you.

Our office cannot accept responsibility for collection of insurance claims or for negotiating a disputed claim with your insurance company. Your eventual reimbursement will be determined by your insurance carrier and it's contract with your employer.

Remember that you, and not your insurance carrier, are ultimately responsible for payment for all the services rendered in our office for your child.

More questions about insurance?
For an excellent Glossary of Dental Insurance Terms you can click on the following links: