Payment Info

As a condition of your treatment by this office, financial arrangements must be made in advance. We depend upon payment from our parties for the dental treatment costs incurred in their care and the financial responsibility on the part of each patient must be determined before treatment. We will discuss financial options with you before rendering treatment.

Click here for information on Carecredit, Lending Club and Smile Club.

Financial Responsibility Agreement

By signing the Financial Responsibility Agreement you are agreeing to all of the terms contained in this Consent for Services including the following:

  1. If you have dental insurance, your estimated portion of payment is due in full at your time of service, unless prior written financial arrangements have been made.
  2. If you do not have dental insurance, payment for services is due in full at your time f service, unless prior written financial arrangements have been made.
  3. There is a $35.00 service charge on all returned checks.
  4. We reserve the right to charge a missed appointment fee for no-shows or cancellations with less than 24-hours notice.
  5. I understand and agree that any account balance not paid within 90 days must be subject to collection activity. I understand Loza Dental will retain the services of an attorney to assist with the collection of any outstanding balance.
  6. I understand and agree that I owe an attorney’s fee of an additional 33 1/3 % of the amount I owe to Loza Dental plus 1 1/2 % per month (18% per annum) on the unpaid balance owed, plus court costs on any account not paid within 90 days of the last date of service.
  7. I understand and agree that, ultimately, I am responsible for payment on my account. As guarantor, I am responsible for any outstanding balances for other family members listed on the same account, due to Loza Dental.


If you have questions about the above, give us a call at 703-777-2442 and we are happy to help.

Leesburg Dental

602 S King St
Suite 302
Leesburg, VA 20175

Phone: 703-777-2442

Hours Of Operation

Mon - 8am to 5pm

Tues - 9am to 6pm

Wed - 8am to 5pm

Thurs - 9am to 6pm

Friday 8am to 1pm

Areas Served

Leesburg, VA
Purcellville, VA
Ashburn, VA
Lovettsville, VA
Winchester, VA
Round Hill, VA
Berryville, VA
Charles Town, WV

Insurances We Accept

AetnaAnthem BlueCross CignaUnited Healthcare Dental United Concordia Dental
Metlife Humana DentalGEHADelta Dental
Northern Virginia Magazine Top Dentist Award
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