Thank you for choosing our office as your dental healthcare provider. It is our mission to create a practice that provides our patients with the highest level of care and concentrates on delivering comprehensive and ethical care. The following is a statement of our financial policy which we require that you read and sign prior to any treatment.
We offer several payment options for your convenience:
Your insurance policy is a contract between you and your insurance company and we are not a party to that contract. Our relationship is with you, the patient, and as a courtesy to you, we will help process your dental insurance claims. We will attempt to verify eligibility and benefits prior to your appointment and will gladly provide you an insurance estimate prior to treatment.
The parent or legal guardian accompanying a minor who has consented to treatment, are responsible for full payment at time of service. Unaccompanied Minors: The parent or legal guardian is responsible for full payment at time of service. Treatment consents and payment arrangements with the parent or legal guardian must be made prior to appointment or non-emergency treatment will be denied.
Please note that any account with an unpaid balance over 30 days is subject to a $25 late fee every month until the balance is addressed. After 90 days, the account will be sent to collections.
The patient (account holder) agrees to be fully responsible for total payment of treatment performed in this office. I understand and agree to this Financial Policy and Agreement. Furthermore, I authorize release of any information relating to this claim or any insurance information. I authorize my insurance company to pay my dental benefits directly to my dental office. I understand that responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered. I understand that I am responsible for all dental treatment not covered by my insurance.
Our goal is to provide the best dental services to our patients and to ensure we are doing that we require a 48-hour cancellation or rescheduling notice. We understand that unforeseen circumstances may arise, which may result in canceling or missing your appointment. As a general rule, there is a cancellation/no-show fee of $50 per hour. If a patient is more than 15 minutes late for their appointment that is considered a no-show and a $50 per hour fee will be assessed unless otherwise discussed with the office staff.
All appointments will require a deposit to be booked. The deposit will be applied to the appointment for the day and if patient does not utilize the full amount of the deposit, the remaining credit will be refunded to the patient. If the patient cancels without a 48 hour notice or does not attend their appointment, the deposit will then be forfeited and used towards the cancellation fee.
A charge will be assessed for multiple missed, short notice, or canceled appointments. Multiple failed appointments may result in being dismissed as a patient from the office.
It is our office financial policy to obtain your credit card number and authorization to process payment for charges not covered by your insurance carrier and for all cosmetic and aesthetic procedures.
In providing your credit card information, you authorize payment by credit card for services in the absence of coverage by your plan including but not limited to co-payments, deductibles, co-insurance, missed appointment and all uncovered services rendered by Sana Dental Studio + Spa and received by you.
This credit card authorization form will allow us to process any no-show/cancellation fees, appointment deposits, and outstanding account balances after insurance payments.
To ensure complete confidentiality, your credit card will be stored directly in your patient record, in a HIPAA and PCI compliant software. To obtain this credit card information, we will call you on the phone number provided and enter the information directly in to the software to ensure it is not written down.
I authorize Sana Dental Studio & Spa to charge my credit card for agreed upon cancellation fees, deposits and outstanding balances.
I understand that my information will be saved to file for future transactions on my account.
Sana Dental Studio + Spa is unlike any dental office you’ve ever experienced. “We are Tampa Bay’s FIRST boutique dental office and full-service med spa specializing in facial aesthetics ranging from all aspects of dentistry to non-surgical cosmetic procedures,” says owner Dr. Sana Yusuf.
Juan Contin wasn’t necessarily looking for a new dentist when his wife Valerie suggested he give Sana Dental Studio and Spa a try. In fact, he was content traveling from his Land O’Lakes home to his dentist in Brooksville for his dental work.
Mon - Thu
Fri
Sat
Sun
9:00 am - 5:00 pm
Aesthetic Services Only
Aesthetic Services Only
Closed