The goal of this practice is to provide exceptional customer service and excellent dental care with both a professional and personal touch. The following policies are implemented so we can better serve you.
We have attached the information for your convenience. Please download, print, and fill out all 5 of these forms prior to your appointment.
If you have any questions regarding any of the forms and/or policies, please contact our friendly staff and we will be more than happy to answer any questions you may have.
We have attached the information for your convenience. Please download, print, and fill out all 5 of these forms prior to your appointment.
If you have any questions regarding any of the forms and/or policies, please contact our friendly staff and we will be more than happy to answer any questions you may have.
New Patient Paperwork
PDF
This form covers all of your account information, including patient profile, Dental Insurance coverage, and emergency contact information. This form requires your signature for our records.
In order to better serve and protect you, we must be aware of any current and prior health conditions you may have had. Please read through carefully before signing.
We need your basic dental history on file. In addition, if there are any other conditions that we must know, there is an area to describe your conditions.
Office Policies
PDF
Co-Payments, Co-Insurance, and Deductibles
-Co-Payments are an estimated amount based on information provided by your insurance company and by you. Co-pays are due and collected on the date of service. We will gladly file your claims, and assist in getting payment from the insurance carrier. However, ultimately all services rendered are the responsibility of the patient and/or guarantor. Insurance carriers change, policies lapse, and numerous other factors beyond our control may alter the actual payment.
We make every effort to research insurance information for you, however patients are ultimately responsible for knowing eligibility, frequency and limitations. Information like this can be found in your handbook or by contacting your plan administrator. Any changes to insurance should be brought to our attention prior to appointments so that we may assist you in filing your claim.
Missed Appointments/Late Cancellations
- Missed appointments and/or appointments canceled less than 24 hours prior to
appointment time may incur a $35 fee. Excessive missed appointments may
result in discharge from the practice.
Delinquent Accounts
-Patients with delinquent accounts will be required to pay their balance in full
prior to making any further appointments. There is a $35.00 charge for any
returned checks.
In printable PDF
-Co-Payments are an estimated amount based on information provided by your insurance company and by you. Co-pays are due and collected on the date of service. We will gladly file your claims, and assist in getting payment from the insurance carrier. However, ultimately all services rendered are the responsibility of the patient and/or guarantor. Insurance carriers change, policies lapse, and numerous other factors beyond our control may alter the actual payment.
We make every effort to research insurance information for you, however patients are ultimately responsible for knowing eligibility, frequency and limitations. Information like this can be found in your handbook or by contacting your plan administrator. Any changes to insurance should be brought to our attention prior to appointments so that we may assist you in filing your claim.
Missed Appointments/Late Cancellations
- Missed appointments and/or appointments canceled less than 24 hours prior to
appointment time may incur a $35 fee. Excessive missed appointments may
result in discharge from the practice.
Delinquent Accounts
-Patients with delinquent accounts will be required to pay their balance in full
prior to making any further appointments. There is a $35.00 charge for any
returned checks.
In printable PDF
In printable Word