Strupp & BrummCosmetic & Restorative Dentistry

William C. Strupp Jr., DDS, FAACD

Michael W. Brumm DMD, CDT, FAACD

Cosmetic and Restorative Dentistry

Office Policies

Please review our office policies below and sign to acknowledge you have read and agree to the terms.

1. No Show / Cancellation Policy

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. We will waive the fee in this policy due to an emergency or in the first instance. However, upon repeated occurrence if an appointment is not cancelled at least 24 hours in advance there will be a $50.00 fee (this will not be covered by your insurance company).

Note: If your appointment is on a Monday, please call the office the Thursday before.

2. Scheduled Appointments

We understand that delays can happen. However, we must try to keep the other patients and doctors on time. If a patient is 15 minutes past their scheduled time, we will have to reschedule the appointment.

3. Account Balances

Patients who have questions about their bills or who would like to discuss a payment plan option may call and ask to speak to an office representative with whom they can review their account and concerns.

Patients with balances over $100 must make payment arrangements prior to future appointments being made.

4. Payment / Insurance Policy

Our office, Brumm Dentistry PA, is not in contract with any insurance companies. Fees are due on the date services are rendered, unless other arrangements have been made. We are happy to submit to your insurance company after these fees are paid in order for you to receive reimbursement from your insurance company (based upon your individual insurance policy).

A finance charge of 18% per year will be added to any account that is delinquent (60 days past due), and Patient and Guarantor shall be jointly and severally liable for all reasonable costs and expenses (including, without limitation, reasonable attorneys' fees) incurred by the Dental Practice in collecting any past due amounts.

Patient / Patient's Guardian

Electronic Signature

I have read and agree to the Office Policies above. Typing my name below constitutes my electronic signature.

We'll confirm receipt by phone or email within one business day.

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