NEW PATIENT REGISTRATION & FORMS
Patient Registration and Health History forms are available to be completed online before your first appointment. Please click on the button below for the following forms:
Once the forms are completed, please click on the submit button on the upper left hand corner. Please read the below additional information regarding the Financial & Insurance, and Office Cancellation policies.
Patient Registration & Forms
FINANCIAL AND INSURANCE POLICY
It is our objective to provide our patients with cutting edge dental treatment, superior dental materials and expert care in a comfortable environment.
In order to provide this quality of dental care, we request that all of our patients pay their estimated personal cost of treatment at the time of their visit. As a courtesy to our patients, we will file your dental insurance claims and bill your dental insurance company for treatments you receive.
However, in the event the insurance company, for any reason does not pay the estimated portion of the bill, the balance will become the patient’s responsibility and will be billed directly to the patient.
Please take the time to read and understand your insurance policy and benefits. In most cases, dental insurance is a contract between your employer and a dental insurance company. The benefits you receive are based on the terms of the contract that was negotiated between your employer and the dental insurance company, and not our dental office. Our goal is to help you achieve and maintain optimal dental care. Our office will do everything possible to help you understand and make the most of your dental insurance benefits. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for at the time services are performed.
A service charge of 1.5% (18% per annum) on the unpaid balance will be charged on all accounts exceeding 30 days, unless previously written financial arrangements are satisfied. Any accounts past due over 90 days will be forwarded to a collection agency.
The fee estimate listed for dental care can only be extended for a period of 30 days from the date of patient examination.
Please feel free to contact our office for any questions or concerns.
OFFICE CANCELLATION POLICY
We pride ourselves in providing extra time for the personal attention each patient deserves. Your appointment time in this office is reserved exclusively for you. We respect your time and make every effort to keep you from waiting. We request that you provide us with at least 48 hours in notice if you need to reschedule or cancel your appointment. We reserve the right to charge a cancellation fee to patients who fail to cancel or reschedule without adequate notice.