Financial Agreement

Financial Relationship Agreement

Dr. Steven W. Haywood, D.D.S. — Please read each section carefully, initial where indicated, and sign at the bottom.

In our office, we do not want money to be an obstacle for you — however dentistry can frequently be expensive. We can always find ways to make things fit into your family budget. We promise to always give you your arrangements and our commitments to you in writing.

Reserving Appointments — We reserve appointments of $500.00 or more with the doctor and for all extensive hygiene or any periodontal care at time of scheduling. We encourage you to make time available for our care and clear your schedule to allow us to provide you the exceptional service you deserve.

Initials *

Prepayment Courtesy — 2%–5% prepayment courtesy is available for those who pay in full at time of scheduling. 10% prepayment courtesy is available for all those 70+ who pay in full at time of scheduling. Full payment is required for all orthodontic cases to be started.

Care Credit and/or Cherry — Can be used to finance your treatment with no interest options up to one year. No other courtesies are able to be overlapped with this option. An initial down payment is customary in order to keep your monthly payments lower.

Initials *

Special Promotions — We frequently have special pricing on services such as Invisalign, implants and teeth whitening. These special offers are promoted as our fee for full payment with cash or check. No other financing options are available at these exceptionally low fees.

Insurance — We do not participate with any insurance company as we are privately owned. We offer the service of submitting your paperwork on your behalf.

We reserve the right to offer our cash price as our best fee. Financing your treatment or paying over time will alter these discounts. Broken/no-show dental appointments and appointments canceled with less than 72 business hours prior notice will incur a fee of $120.00 or the cost of the appointment at the discretion of this office. A 2% monthly finance charge is automatically added to any unpaid balance.

Initials *

Patient Acknowledgment & Signature

I understand and accept the terms of this financial relationship with the offices of Dr. Steven W. Haywood DDS. I understand I am ultimately personally responsible for all fees incurred for diagnosis or treatment by Dr. Steven W. Haywood DDS or associates. Any fees for collection of debt including legal fees will be my responsibility.

Patient Full Name *

Date *

Phone Number *

Type your full legal name as your digital signature

Digital signature — legally equivalent to a handwritten signature

Office Staff Signature: _________________________________ Date: _______________

To be completed in office

SWH… 4/3/25

✓

Agreement Submitted!

Your Financial Agreement has been sent to Dr. Steven W. Haywood DDS. Our team will have a copy ready for your records when you arrive.

Questions? Call us at (410) 453-9399.