Financial Agreement Form

It is a pleasure to welcome you to our family dental practice.Our goal is to provide you with quality care and attention during your appointment.


We ask that you make every effort to keep your appointments. This appointment time has been set aside for you; missing it will disrupt proper sequencing of your care and delay completion of your treatment. Our office utilizes a confirmation system that will contact you before your appointment by email, text or phone call. We ask that you please confirm your appointment via this system so we can adequately prepare for your appointment. If you miss this confirmation call, please call our office to confirm your appointment. We ask that you call at least 24 hours before your appointment if you need to cancel or reschedule. Failure to call 24 hours before will result in a broken appointment fee. We understand that family emergencies or sudden illnesses do arise, but please call the office to reschedule if this happens. When we have adequate notice of a cancellation, we are more likely to be able to offer that time to another patient. After three broken or missed appointments you will be dismissed from our practice.


Payment is due at time of service. Our office accepts cash, personal checks, Master Card, Visa, Discover, American Express and Care Credit.


As a courtesy to you, we will help you process all of your dental insurance claims. Insurance coverage is subject to eliminations, exclusions, waiting periods, frequencies, age restrictions, deductibles, and maximums. It is your responsibility to be familiar with your dental plan. You may need to contact your insurance company to obtain your dental plan benefit information. We will provide you with an insurance estimate. This however is not a guarantee that your insurance will pay the exact amount estimated. Your benefits may differ due to a number of reasons as stated above. Your insurance company and your plan benefits ultimately determine the amount paid. Our office is committed to providing the best treatment for our patients. All charges you incur will be your responsibility, regardless of what your insurance covers. We must emphasize that as your dental care provider our relationship is with you, our patient, not your insurance company. We encourage you to be up to date with your coverage.

We ask that you please read and sign this letter as confirmation that you understand our office expectations. You will be given a copy to keep for future reference.

Thank you for coming to our office. We look forward to getting to know you and your family.

Patient Signature

Click to Sign



Dear Patient Family,

The COVID-19 pandemic has been a difficult time for all of us. Many of you have been forced to wait for dental care and we appreciate your understanding while we kept our office closed to follow orders from the Governor's Office.

We are happy to say that we are opening our office for all patient treatment on June 1st, 2020. Our hours of operation will go back to normal, Monday-Thursday 8am - 5pm. We want you to know that there will be some changes at your next appointment. Please be patient with us as our protocols will inevitably change as new guidelines are released.

  • We ask that you use our parking lot as the waiting room.
  • Please wear a mask when you come into the office and leave it on until entering the treatment room. Homemade is acceptable.
  • Only the person receiving treatment should come in the building, all others will be asked to wait in the car if at all possible. The exception will be for our minor patients who may have one parent accompany them.
  • We will be asking you some questions when you arrive at the office and we will also be taking your temperature.
  • We will not be able to offer magazines, drinks, or toys at this time as they cannot be disinfected to our standards. Eventually this will change and we will be happy to offer our amenities once again.

These changes have been made to adhere to the latest CDC guidelines and for the benefit of our patients and our staff. We want you to know that our office has always taken the safety of our patients very seriously and that we will continue to follow the highest levels of sterilization and disinfection to keep you protected. If you would like more information on what measures we have taken we would be more than happy to answer any questions you may have.

We cannot say how excited we are to see all of our patients again and to provide for their dental needs. We look forward to seeing all of your smiling faces soon!

Dr. Habecker and Team