Financial Agreement - Red Barn Dental, Family Dentistry in Middletown New Jersey,

Full Name*

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Payment is expected at the time of service unless other financial arrangements have been discussed.

I understand these terms. *

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We will gladly process your primary and secondary insurance claims with the following understanding:

Dental insurance is an agreement between you and your insurance company; therefore we can only estimate your dental benefits. This estimate is not a guarantee of payment by your insurance company. You are responsible for any charges your insurance company does not pay.
Your out-of-pocket portion and deductibles are due at the time of service.

I understand these terms.*

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Primary Insurance

ID#

Subscriber Name

DOB

Secondary Insurance

ID#

Subscriber Name

DOB

I understand these terms. *

Please type your initials above in agreement.