Please be advised that payment is due and payable at the time services are rendered, unless prior financial arrangements have been made. If applicable, dental/medical insurance is a contract between the insurance carrier and you, and not between the insurance carrier and Dr. Samani. You are fully responsible for all fees at time of service. Any payments sent to Dr. Samani from your insurance carrier will be credited to your account or refunded if the dental fees incurred have been paid. In the event that your account is referred to a collection agency or attorney you will be responsible for any reasonable collection fees and/or legal fees.
Enter your name and email address below, as your signature and acceptance of this Agreement.
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