Save time; fill out these forms before you come in to see us
You’ll be able to save time by downloading our New Patient Paperwork PDFs, filling them out, and bringing them to your first appointment. If you are a New Patient, download either the Adult or Children’s PDFs to your computer and print them out. Also download the Other Forms (#3) and print them out as well.
Please fill out both pages and bring to your first appointment.
Please fill out and bring to your child’s first appointment.
Pages 1-2: Notice of Privacy Practices: Please review
Pages 3-6: Facts About Fillings: Please review
Page 7: Authorization and Informed Consent for Treatment: Please read and Sign
Page 8: Acknowledgement of Receipt: Please Sign
Please bring all of your signed pages to your first appointment.
Policies | Financial | Insurance
We look forward to serving your dental needs and working with you to improve both your dental and overall health.
We hope the information below will be helpful as you become a valued patient in our practice.
If at any time you have any questions don’t hesitate to call our office. We appreciate your business and are more than willing to work with your individual account and customize a payment plan for you. We realize that dental work can be a large and sometimes unexpected expense. Please also take a moment to review our policies too. Thanks
We require payment at the time of services rendered, especially for routine cleanings and exams. We realize the more extensive procedures require more budget planning: an outline of those policies follows.
If you have insurance, we will kindly submit insurance claims for you for routine cleanings and exams. For more extensive dental procedures such as fillings, crowns, dentures, partial crowns or inlays/ onlays we require a 50% up-front payment. This should be paid on or before your first appointment date. The remainder is to be paid within 30-60 days. For large full-mouth reconstructive procedures, we are happy to help set up a third party financial arrangement such as CareCredit.
If you should need to cancel an appointment we require 24 hours notice, so as to not disrupt our schedule. We understand that last minute situations can arise, so the first time we will just remind you of our policy. Thereafter, a $75 charge will be applied for any last minute cancellation.
Our accountant will be reviewing all accounts monthly. Any account which is more than 60 days overdue and has not made a payment, will receive a past due sticker reminder and a phone call along with their bill. The following month, if we have not heard from you or have not received a payment, you will receive a final notice sticker, informing you of our plans for collective action if no payment is made within 30 days. By the next month, if we still haven’t heard from you, your account will be turned over to our collection agency. This is our last resort! We would prefer to work out a payment plan with you.
As long as you continue to make consistent monthly payments, no further action will be taken.
We accept Visa, MC & AMX, personal checks, money orders and cash.
What is typical reimbursement for dental procedures?
Typical % of Reimbursement are as follows:
- Preventive Procedures 100% (cleaning, exams, x-rays)
- Basic Procedures 80% (fillings)
- Major Procedures 50% (crowns, bridges etc.)
Are there dollar limits to what my insurance will cover?
Most companies have an annual maximum of $1000-2000 a year. This means they will only pay out that much in benefits for the year (including your routine cleanings) and the rest of the expenses are out of pocket. Most policies also have a $50-100 deductible that is waved for preventive procedures, but applied on basic and major procedures.
Are there time limits to what my insurance will cover?
Frequency of Benefits: Most insurance companies will pay for 2 cleanings a year, one set of bitewing x-rays and an exam. They will also include a full mouth series of x-rays every 3-5 years. Other benefits depend on your individual plan.
Our office accepts Visa, Mastercard, AMX, money orders, cash and personal checks. In addition to these payment methods we offer a no-interest financing plan for through Care Credit. We realize dental fees can be expensive and our office is happy to help you with payment plans, insurance questions etc.