Patient Intake Form
Harmony Dental Arts
1066 Clifton Ave, Clifton,Clifton Ave, NJ, 070139737772731
Please mark any of the following to indicate Yes in response to the question:
-We will accept assignment of your insurance benefits at the time of your visit(s). However, we do require your co pay and deductible at the time of service. Also, you will be billed for any amount that your insurance states is not dentally necessary and/ or are not covered under your contract. Insurance is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible, coinsurance, or any other balance determined by your insurance company to be your responsibility.If payments are 30 days late or more you will
-The adult accompanying a minor and the patient (or guardian of the minor) is responsible for payment. For unaccompanied minors, non-emergency treatment will
-In case of rescheduling or cancelling appointments, a minimum of 24 hr is required to avoid a $75 fee unless it is true emergency.