Our Practice Policy is that full payment is required on the day of service.
Item numbers on our statement represent as accurately as possible the procedures performed, but in no way are they a claim on anyone other than the patient for whom they were performed. The eligibility of the patient or the procedures, to attract refunds, and the rates of those refunds, are determined by the conditions of the patient's health insurance policy. We accept no responsibility to either party, for any decision the insurer may make regarding the refund of monies to the patient.
I have completed this questionnaire to the best of my knowledge, and understand that failure to make a full disclosure may place ME at undue medical risk. I understand that notes, radiographs (x-rays), or models relating to my treatment may need to be sent to other dental practitioners to aid them in my treatment and consent to this.
Thank you for your message.
Level 3, 25 King William Street, Adelaide, South Australia 5000Endodontic Solutions Pty Ltd
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