Patient Information

Financial Policies

• You are responsible for all fees related to your dental care and treatment
• Full payment for all dental treatment is to be paid at the time the treatment is performed
• All account balances over 30 days old may incur a monthly interest charge at the maximum rate allowed

Broken and/or Missed Appointments

Rivergate Village Dental reserves the right to charge a $35 fee for any appointment not kept by the patient. After two (2) broken or missed appointments, the dentist retains the right to discontinue elective treatment.

Patients with Dental Insurance

• Your insurance policy is a contract between you and your insurance company. Rivergate Village Dental and its employees are not parties to the contract with your insurance.
• You are ultimately responsible for and all balances, even if your insurance company agrees to pay a balance and later does not pay.
• You may be given the option of only paying the estimated portion (that portion not covered by insurance) at the time of services. As a courtesy, the office will send your claim to the insurance company. If your insurance company fails to pay the balance, the balance is your responsibility and payment is due in full.

Patient Forms

To help us better serve you, please print and complete the appropriate patient forms before your first office visit. As a convience, you can download a patient form below. Please feel free to call our office if you have any questions regrading the forms or our visit.

• New Patient Form
• Medical History Form