RAFIA DENTAL PATIENT FINANCIAL AGREEMENT
We stand strong in our commitment to help our patients achieve ultimate oral health. 
We offer the following agreement and payment options. 

**ALL ESTIMATED FEES ARE DUE AT THE TIME OF SERVICE**

FOR OUR PATIENTS WITH DENTAL INSURANCE:
We will gladly verify your dental benefits and process your primary and secondary insurance claims with the following agreement: 

IF WE ARE NOT BILLING DENTAL INSURANCE:

PAYMENT OPTIONS:

MISSED APPOINTMENTS OR SHORT NOTICE CANCELLATIONS:
We understand that your plans and daily schedule can change.  When they do, a 24 hr notice is greatly appreciated when you need to reschedule your appointment.  A fee of $25.00 will be assessed to cancelations with less than 24 hrs notice and a fee of $50.00 will be assessed with no notice prior to appointment. 

GUARANTEE OF WORK:
Rafia Dental guarantees its dental work for 24 months after the service has been completed, provided you have maintained 2 regularly scheduled preventive appointments annually. 

I have read, understand and agree to all of the above.  I have been given the opportunity to ask questions.  If I have insurance, I hereby authorize my insurance company to pay my dental benefits directly to the doctor.  I authorize Rafia Dental to release any of medical information to my insurance company as needed to process my insurance claim. 
**FORM WILL BE SIGNED ELECTRONICALLY AT THE FRONT DESK**