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Scheduling Policy

A deposit of $800.00 is required to schedule your sedation appointment. Your dentistʼs office may obtain, process and facilitate payment (Visa/MC/Amex only) on behalf of Dr. Ali/NOVA Dental Anesthesia LLC. We require a valid credit card on file to collect any residual balance. The provided Credit Card information is proof of your authorization to process outstanding unpaid payment or charges or in case a cancellation policy is applied.

Cancellation/Rescheduling Policy

If the patient does not appear on time or failed to keep the scheduled appointment time as agreed, a non- refundable charge of $800.00 will be applied. If the patient did not adhere to our fasting, eating or drinking restrictions, and ingested food or unapproved liquids, the appointment will be cancelled for his/her safety. A non-refundable charge of $800.00 will be applied. Rescheduling due to unexpected illness or family emergency may require a physician/pediatrician clearance. The $800.00 fee will be credited (but NOT refunded) toward your next available appointment.

Sedation Fees

Total final sedation fee may vary upon the total time required for the actual treatment rendered and is based upon x-rays findings, clinical evaluation and diagnosis by the dentist. Most dental insurances and medical insurances will not cover IV Sedation performed in the office. We do not participate with any insurance including Medicaid, Tricare, Medicare or accept their payments or fees schedule. You are responsible for all sedation charges/ balances at the day of of your appointment.
We Do Not Accept Any Insurance Payments On Your Behalf.
Any medical insurance filing for IV Sedation will need to be completed and mailed by you on forms provided by the insurance company. Insurance is a contract between you and your insurance company, we are not part of that contract. We will not become involved in a dispute between you and your insurance company regarding deductible, co-payments, cover charges, “usual and customary” charges, etc., other than to provide factual information. We require a valid credit card information on file to collect any residual balance, interests, delinquencies, and uncollected debt.

Sedation Fees

*Deposit (1st Hour Minimum): $800.00                                                                           1st Hour of Sedation: $800
Estimated IV Sedation Time: ________                                                                                 Each Add. Hour:        $800
Estimated IV Sedation Fee : ________                                                                                   Each Add. 15 Mins:   $200
* Some Restrictions May Apply
Patient Information

I have read and understand the above information. I agree to accept these terms and conditions. Please sign and date below. Please return this form to your dentistʼs office.

Patient Name: Date of Service:

Relation to Patient: Signature:


Credit Card No. (Visa/MC/Amex):Exp. Date:

Security Code: Dentist Name / Office