Requested Online Scheduling - {{cf7-field-id-patient-first-name}} {{cf7-field-id-patient-last-name}}


Signed Online Scheduling Form

 

 

Patient Info

Patient Name

Invoice #

Date of Service

DOB

Dentist Name

Gender

Parent Name

Email Address

Address

  

City

State

Zip

  

Cell Phone

Home Phone

Work Phone

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Estimated Dental
Procedure Minutes		 Total Prepaid Fee Deposit due at scheduling Balance due prior to procedure
5 $475 $250 $225
20 $750 $250 $500
40 $1000 $250 $750
60 $1200 $250 $950
80 $1500 $250 $1250
100 $1800 $250 $1550
120 $2000 $250 $1750
140 $2300 $250 $2050
160 $2600 $250 $2350
180 $2800 $250 $2550
200 $3100 $250 $2850
220 $3300 $250 $3050
240 $3600 $250 $3350

 

Payment Policy:

  • $250 Deposit is due at the time of scheduling. There is a $250 charge for patients who fail to keep the IV
    Sedation appointment without giving us a 24 hour notice.
  • The card on file will be charged automatically for the balance 3 business days prior to the procedure date.
  • On the day of the patient’s procedure, you will be given a Superbill to file the anesthesia through your out of network benefits.
    Many medical insurance companies do not cover anesthesia services for office based dental care.
  • Your dental treatment plan may change after treatment is begun. Charges for anesthesia services may
    be more or less than the estimated amount based on the final length of the procedure. The anesthesia
    charges may be more than initially estimated and an additional payment by credit card is due at the
    time of service. Any overpayments will be refunded automatically to you.
  • We accept cashier’s check, American Express, Discover, Visa, MasterCard, and Carecredit for payment
    in full 3 business days before the patient is treated. You can apply for Carecredit at www.carecredit.com
  • I authorize PDAA to send me text messages via SMS texting regarding my child's anesthesia appointment and finances. I understand standard text message and data rates may apply.
  • I understand that my health plan (Tricare and other plans) may impose a limit on balance billing by out of
    network providers. I wish to waive any limit on balance billing and receive treatment from this out of network
    provider.
  • I understand that I am seeking the care of PDAA for a service that may not be covered by my insurance
    company. I understand that my insurance plan may not cover any part of the charges, costs or expenses
    related to Anesthesia services and I will be responsible for all charges incurred.

May 18, 2025

 

 

 

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