Payment & Forms
Click on the links below to view and/or save these form files in PDF format. Fill out the forms and email to [email protected] or fax to (650) 282-4187.
Forms
Pediatric Patients:
- Important Patient Instructions and Guidelines
- Confidential Medical History and Consent
- Pediatric Post-Op Instructions
- Designation of Financial Responsibility
Adult Patients:
- Important Patient Instructions and Guidelines
- Confidential Medical History and Consent
- Adult Post-Op Instructions
- Designation of Financial Responsibility
Food & Drink Guidelines:
Payment
A NON-REFUNDABLE DEPOSIT will secure your scheduled appointment. The remaining balance is due on the day of the procedure, and will be automatically charged to this same card, on or after the day treatment is completed, unless prior arrangements are made. An estimate of anesthesia costs can be provided upon request, when accompanied by a total treatment time estimate from your Dentist. We accept all major credit cards. If you would like to pay using CareCredit’s six-month interest free term, please call our office at (650) 282-4171, since this transaction must be managed by phone.
As a reminder, Bay Anesthesia Group is a PRIVATE, FEE FOR SERVICE practice and does NOT accept insurance. Upon request, we can provide you with an itemized receipt and a copy of the anesthesia record, from the day of treatment, that you may submit directly to your insurance company for potential Out of Network reimbursement. We do not guarantee that you will receive reimbursement from your insurance company. Please contact your carrier directly, for any questions regarding your coverage, their payment policies, and reimbursement procedures.
For additional information on our Payment Policies, please CLICK HERE. *Please utilize the “Description” field to enter Patient Name & DOB.* This will ensure your deposit is applied appropriately. Thank you!
Financing
If you are interested in applying for financing through CareCredit, please use the link below to apply directly through their website. Once your application is approved, you will be able to utilize your new account for payment on anesthesia services. All transactions will have a 6 month interest free promotion from the date of service. Should you choose to continue making payments beyond the 6 month promotion, interest will apply. Please refer to your CareCredit account for details.
We accept all major credit cards. If you would like to pay using CareCredit’s six-month interest free term, please call our office at (650) 282-4171, since this transaction must be managed by phone.