If you have additional insurance, please bring it with you and inform our staff at your next appointment.
We require 24 hour notice in the event of a cancellation. There is a service fee of $75 for no-show or cancellation without 24 hour prior notification. This charge will not be covered by insurance.
By reading this statement, I hereby authorize Michael P. Cheng D.D.S. to charge my credit card for any appointment missed without proper notification:
Authorization and Release
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my status.
I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment.
I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or for my dependents.