Financial/Change in Treatment Agreement

Grand Rapids Childrens Dentist

"*" indicates required fields

Financial/Change in Treatment Agreement

Thank you for choosing our office for your child’s dental care needs. We are committed to providing exceptional dental care and helping your child achieve ultimate oral health.

**All estimated fees are due 1 week prior to the scheduled surgery date**
(You may request to make this payment by phone or through text)


We will gladly verify your dental benefits and process your insurance claims with the following agreement:

  • Your dental insurance is an agreement between you and your insurance company
  • All patient copayments and/or patient portions are only an estimate/never a guarantee of payment
  • As part of your contract with your dental insurance company, you are responsible for all out of pocket portions/copayments and deductibles
  • Insurance payments not paid after 90 days will become your complete responsibility


A copy of the treatment plan has been provided. The proposed treatment plan is made based on a clinical examination and any x-rays that we were able to obtain. Depending on the temperament of the child we may not have been able to obtain optimal x-rays or complete a thorough examination in the office. Once the child is under general anesthesia the doctor will complete a thorough examination and obtain any further x-rays that are needed. Consequently, the final treatment may vary from the proposed treatment.

  • If the doctor determines that additional treatment is required, they will proceed with the treatment  while the child is under anesthesia.
  • If additional treatment is done, you will be responsible for additional charges not covered by your dental insurance

By initialing and signing below I acknowledge:

I have read, understand and agree to the above terms and conditions.*
I have been given the opportunity to ask questions.*
I understand that I am expected to pay any copays or deductibles 1 week prior to the surgery. At that me my credit/debit card information will be securely stored on my account.*
I understand that the credit/debit card I have stored will automatically be processed for any remaining balance, up to $500, after my insurance has processed the claim. If the amount due is over $500 I will be contacted to approve that amount.*
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.