Financial Policy

Thank you for choosing 419 Dental for your dentistry needs. Please complete the form below, and a member of our team will reach out if we have any questions. If you have any questions, please feel free to contact us.

Financial Policy Form

Please fill out our financial policy form in its entirety to ensure we can provide you with the best possible care.

Note: Any fields with * are required.

This agreement is to inform you of your financial obligation to our practice. This financial agreement is intended to facilitate our ability to provide excellent service to you while minimizing our administrative costs.


As a courtesy to you, we will help you process all your insurance claims. In order for our practice to file your insurance claim, you must provide proof of insurance either with a card or information provided to the office when setting up the appointment. All charges you incur are your responsibility regardless of your insurance coverage.

Payment Due at Time of Service

Our policy is: “Payment Due at Time of Service”. Your estimated co-payment for treatment, which is the amount not covered by insurance, is due at the time treatment is provided. Your estimated co-payment may be adjusted after the time of treatment depending on the final reconciliation of insurance payments. If you do not have insurance, we expect full payment for service at each office visit.

We accept these forms of payment:

Cash | Check | Mastercard | Visa | Discover | American Express | CareCredit

Please don’t hesitate to ask if you have any questions regarding this financial agreement. We are committed to providing you with the ultimate experience in dental care but need your financial commitment as well.

Clear Signature

Appointment Policy

I understand the cancellation policy which states “Reserved times canceled within 48 hours are subject to a $50.00 cancellation fee”. An appointment canceled within 48 hours limits our ability to fill the time with a patient in need. We appreciated your understanding and working with us to avoid this scenario.

Clear Signature