Mobile dental anesthesia provider servicing Aldrich Pediatric Dentistry
We know there aren't any mountains in Indiana. We just wanted to bring our Colorado name with us.
Click the box above to complete the medical history prior to anesthesia
Haga clic en el cuadro de arriba para completar el historial médico antes de la anestesia
All patients or guardians must fill out the financial agreement
ANESTHESIA DEPOSIT AND FEES
To submit payment for the deposit please use the links below. The entire fee for the anesthesia services rendered is determined by the length of the surgery being performed. The final bill will be available as soon as the surgery is compete. Dr. Yancey currently accepts fee-for-service only. This bill is provided to help patients submit this to their private insurance if they choose to do so.
Once the deposit is received your appointment will be confirmed. Full payment is required on the day of anesthesia. After submitting the deposit please sign electronically the financial agreement below.
Please don't hesitate to email our staff at info@mountainda.com with any payment questions. Thank You.
PEDIATRIC PATIENTS (13 years old and younger)
ADULT PATIENTS (14 years old and older)
PEDIATRIC FEES
1. $1000 fee for every case which is 1 hours or less
2. $1300 for cases between 1 hour and 1 hour and 30 minutes
3. $1600 for cases between 1 hour and 30 minutes and 2 hours
4. For cases longer than 2 hours and additional $600/hr will be billed in 15 minute increments
PEDIATRIC DEPOSIT
There is a mandatory $500 deposit in order to hold the appointment.
ADULT DEPOSIT
There is a mandatory $750 deposit in order to hold the appointment.
Please sign the financial agreement below. Thank you
Please sign the financial agreement below. Thank you
ADULT FEES
1. $1000 fee for every case which is 1 hours or less
2. $1300 for cases between 1 hour and 1 hour and 30 minutes
3. $1600 for cases between 1 hour and 30 minutes and 2 hours
4. For cases longer than 2 hours and additional $600/hr will be billed in 15 minute increments
Custom Payment/ Remaining Payment
You can submit the remainder of your payment using the following button:
Mountain dental anesthesia fees are separate from the dental/surgery fees. Mountain dental anesthesia accepts all major credit cards and cash. Ask about a cash discount.
Both of these forms can be signed electronically above