New Patient Forms
Please read the following form:
Please print and complete the following forms and bring to your appointment
- Account Information/ Assignment of Benefits Form
- Patient Medical History
- Universal Precautions and Patient Rights
- Consent for Disclosure
We accept all insurance plans, as well as Visa, MasterCard, American Express and Discover. Since we believe in affordable, accessible dental care for everyone, we also offer qualified patients, CareCredit®, a convenient, low minimum monthly payment program.
Charges for our services are reasonable and competitive. In most cases, our charges and insurance Usual and Customary (UCR) fees are the same. Prior to your initial appointment, our front office team will contact your insurance company and obtain a general breakdown of benefits with general guidelines of coverage. Calculated estimated copayments based on the information received from your insurance company will be collected at the end of your visit.
In the event your insurance company does not pay the previously estimated amount, it is the patient’s responsibility to remit the remaining balance upon receipt of statement. Please remember you are responsible for fees charged by this office regardless of your insurance coverage.
We accept all insurance plans. However, for some insurance plans we are considered out-of-network. For these plans, the insurance payment is based on the Usual and Customary (UCR) fees. UCR fees are determined by your insurance company and your employer. There is no regulation for determining these fees; therefore, they can vary widely from plan to plan. In most cases, our charges and insurance Usual & Customary fees are the same.
Many dental offices double or triple book their schedule. We do not do this. We set aside time solely for each patient; this insures that each patient receives the attention and care they need.
In the event that you need to reschedule or cancel an appointment, a minimum of 24 hour notice is required. This notice allows us time to contact another patient in need of care. If the minimum time requested is not given, a $20 fee will be applied to your account.
Patients in Treatment Rooms
Only patients receiving dental care are allowed in treatment rooms. There are several reasons for this policy including patient privacy and Federal OSHA guidelines addressing airborne pathogens. In addition, our treatment rooms are designed to accommodate patients and clinicians, not additional seating for non-patients.
Young children are provided dental care unaccompanied by their parents. This separation allows the child to focus on the instructions given by our clinical staff. Our goal is to help children experience an educational, comfortable and enjoyable visit while maintaining quality of care.
Cellular Phone Policy
The use of cellular phones is allowed in our reception area. Patients are asked to turn off their cellular phone while receiving care in our treatment rooms. If special accommodation is needed, our front office team will be happy to receive a message of importance during your appointment.