Armendariz Family Dentistry
18555 N. 79TH AVE. SUITE B-104
GLENDALE, AZ 85308
Financial Agreement-Please read the following information completely.
If you do not have dental insurance, the total fee is your responsibility.
Payment is expected at the time of service. If you are unable to pay for services in
full, please feel free to speak with Sherrie prior to having your
treatment started to review payment options we have available. For your
convenience, we accept cash, checks, VISA, Mastercard, Care Credit and
As a courtesy to our patients with dental insurance, we are happy to assist in
filing insurance claims for you. Please understand that dental benefits paid by
your insurance carrier are determined by a contract between your employer and
the insurance company and we can only provide an estimate of benefits. Any
unpaid balance is your responsibility. We only provide composite (tooth-colored)
fillings and some insurance companies may apply an alternate benefit for amalgam
(silver) fillings. I authorize the release of any required information to my
insurance company and authorize payment directly to Armendariz Family Dentistry for any claims
submitted on my behalf
If you are unable to keep your appointment, we request at least TWO
BUSINESS DAYS notice so we may give this time to another patient. Failure
to do so may result in a missed appointment charge of $50.00. Please keep in
mind, our days of business are Monday through Thursday.
I (we) agree to pay court costs, attorney fees and up to 50% of the collection fee
on any outstanding balances that require placement with an outside agency.