Personal Information

First Name

Last Name

Email Address

Phone

Payment Methods

Fresh offers two solutions of handling payments from patients with dental insurance coverage. Please select the method that works best for you.

Patient pays in full at time of service, Fresh will send paper work to your insurance company, who will then reimburse you directly, usually in a couple of weeks, often sooner. This is a great option for those clients who collect travel points on a credit card.

Fresh accepts direct payment from the clients insurance company for services performed, and any outstanding balance are paid by you. However, Fresh will require that you to leave a valid credit card number on your file. This will allow us to apply any outstanding balances not covered by your dental plan. Please provide this information in person, for security purposes at your next dental hygiene visit. In keeping "green", Fresh will email you a statement of charges for your record.

I have read and agree to the above office policy of Fresh Dental Hygiene & Whitening Spa Inc. I understand that I am fully responsible for payment of fees of all services rendered, regardless of my insurance coverage.