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Adult Private Pay Financial Agreement Form

  • Welcome to CarePoint Anesthesia Group! We are dedicated to providing specialized anesthesia services to the familiar and comfortable environment of your dentist’s office, bringing a tailored and personal touch to your care. We would also like to inform you of your financial obligations. The following is our company’s financial policy:
  • Payment can be made through our website at​. ​Should the dental procedure exceed the allocated 1 hour, an additional $150 per 15-minute increments will be accessed. The remaining balance will be charged to the card on file unless other arrangements have been made​. We accept all major credit cards, debit cards, Health Savings Account (HSA), flex spending cards, CareCredit (6-months term), cash, money orders, or checks for our services.
  • I certify that I have read, understood, and acknowledge receipt of a copy of the above Financial Policy. I also understand and acknowledge my financial responsibility for the anesthesia services provided by CarePoint Anesthesia Group, LLC.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY