Dr. Hanratty and staff have instituted this agreement in order to meet our patient’s expectation of the highest quality of care and customer service. Please review this CAREFULLY and acknowledge with your signature below.

Co-Payments, Co-Insurance, and Deductibles
-Co-Payments are an ESTIMATED payment based on information provided by your insurance company and by you. Co-pays are due and collected on the date of service. We will gladly file your claims, and assist in getting payment from the insurance carrier. However, ultimately all services rendered are the responsibility of the patient and/or guarantor. Insurance carriers change, policies lapse, and numerous other factors beyond our control may alter the actual payment.
-There are literally hundreds of different dental insurance plans in our
Patient population, so it is not possible for us to know precisely what benefits are for any given claim. We make every effort to research insurance information for you, however patients are ultimately responsible for knowing eligibility, frequency and limitations. Information like this can be found in your handbook or by contacting your plan administrator. Any changes to insurance should be brought to our attention prior to appointments so that we may do our research.

Missed Appointments/Late Cancellations/Inappropriate Behavior
     -Our office uses an automated confirmation service thru email and text. It is
       your responsibility as the patient to manage your schedule and keep the
       appointments made with our office. Missed and late cancelled appointments
       represent a cost to us and to other patients who may have been seen in the
       time set aside for you. We ask for no less than 24 hour notice to cancel or
       reschedule your appointment. Failure to do so will result in a charge based
       on the appointment type cancelled. For example a cleaning appointment
       will incur a charge of 65.00 dollars. Longer appointments will be 20% of
       the procedure that was scheduled.       
       Excessive missed appointments and threatening behavior will result in
       discharge from the practice.

Delinquent Accounts
       -Patients with delinquent accounts will be required to pay their balance in full
       prior to making any further appointments. There is a $35.00 charge for any
       returned checks. 

This form covers all of your account information, including patient profile, Dental Insurance coverage, and emergency contact information. This form requires your signature for our records.

In order to better serve and protect you, we must be aware of any current and prior health conditions you may have had. Please read through carefully before signing.
We need your basic dental history on file. In addition, if there are any other conditions that we must know, there is an area to describe your conditions.