Your responsibility
I understand that I am financially responsible for all charges not covered by my dental insurance, and that payment for services is due at the time of treatment unless other arrangements have been made in advance with the practice's billing team.
Estimates
Estimates provided before treatment are good-faith estimates only. They are based on the benefit information available at the time, and my actual insurance benefit may differ once a claim is processed. Any difference remains my responsibility.
Insurance is between you and your plan
The practice will submit claims to my dental plan as a courtesy. The contract for benefits is between me and my plan, and the practice cannot guarantee what the plan will pay.
If a claim has not been paid within 60 days, the balance may become my responsibility.
Payment methods and arrangements
The practice accepts the payment methods listed at the front desk. If the cost of recommended treatment is a concern, please ask — arrangements can often be made in advance, and it is much easier to arrange before treatment than after.
Missed appointments
Missed appointments and late cancellations are covered by the Cancellation and No-show Policy, which is a separate document.
Contact Us
Esthetique Dentistry of Ashburn
44121 Leesburg Pike, Suite 225
Ashburn, VA 20147
Phone: (703) 729-6222
Last revised 19 August 2026