Webform: Payment Agreement

    Payment Agreement


    Consideration for insurance billing:

    If your insurance plan allows, we can bill your insurance company directly. However, we require a credit card be provided to secure the balance, and the patient’s portion must be paid at the time of the treatment.

    Your card will be billed any remaining portion, or service not covered by your insurance.

    Please note that insurance companies may take up to 90 days to pay dental offices, and your card will be charged at the time. We will notify you of any charges, and a receipt will be provided.

    “By signing, I, the patient, allow Vancouver Dental Specialty Clinic, to keep a current credit card on file. I agree to pay my portion of the services provided at the time of the treatment. I consent to Vancouver Dental Specialty Clinic to charge my credit card on file, any outstanding portion unpaid by my insurance.”


    Patient, parent, or guardian:
    Date:

    3488 West Broadway

    Vancouver, BC, V6R 2B3

    604-336-0958

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