Shoreline Dental Care L.L.C.

Financial Policy

Thank you for choosing our office for your dental needs. Our team offers efficient and experienced service, always listening to you and being respectful of the time you spend with us. We realize that everyone’s financial situation is different. For this reason, we have worked hard to provide you with a variety of payment options to help you receive the dental care you need and deserve…options that will allow you to enjoy a healthy, beautiful smile with respect to your budget. 

In the interest of better understanding, we believe that financial arrangements must be completely understood and agreed upon, before treatment has begun. Your treatment will be explained to you and you will be given an estimate of fees. 

All our fees are due and payable at the time treatment is rendered.
Payment options:

  1. Cash and Checks are accepted. Personal or bank checks, ATM Debit Cards and money orders are welcome. An appointment deposit may be required when scheduling large blocks of time.
  2. Credit Cards: We are happy to accept MasterCard, Visa, American Express, or Discover. An appointment deposit may be required when scheduling large blocks of time.

  3. Seniors: We are happy to offer our seniors (age 65 and older) a 5% courtesy on all treatment when it is paid in full at the time of scheduling or time of service by cash, check or credit card.
  4. Dental Insurance: Insurance deductible, co-payments, and fees or portions not covered by your insurance company are also due at the time of scheduling/time of service and are payable in the same fashion as stated above.

Payment Options if you would like to be billed

  1. Monthly Payments: Direct drafting of your credit card on a pre-determined date each month, over two (2) consecutive months. A 50% deposit is required and prearranged automatic withdrawals will be processed to your account.
  2. Billing Accounts: If you require an extended period to pay your balance, we will be happy to discuss the advantages of using CareCredit™, which will afford you small monthly minimum payments. Low-Interest as well as No-Interest options are available.

Please feel free to discuss any of the above payment options with our Treatment Coordinator.

I have read and received a copy of the Shoreline Dental Care LLC Financial Policy. I understand that the Shoreline Dental Care LLC Financial Policy applies to me, and anyone on my account that I am legally responsible for (spouse, children, and legal dependents).


Patient Name

HIPAA Policy
I have read and understand the Notice of Privacy Practices for Shoreline Dental Care, LLC. I have been given a copy to retain for my personal records.