• Patient Information

    All information is CONFIDENTIAL. Fields marked with a * are required
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  • Responsible Party

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  • Insurance Information

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  • Insurance Information #2

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  • Patient Medical History

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  • Patient Dental History

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  • Authorization and Release

  • I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information, inluding the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

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  • Financial Policy

  • We at Dental Arts are proud to be part of a team whose primary mission is to deliver the finest and most comprehensive health care available today. Your clear understanding of our Financial Policy is important to our professional relationship.

    • New Patient must fill out patient information forms prior to seeing the doctor.
    • We will request to photocopy your Insurance card (s) and Driver’s License for your record.
    • Co-payments and annual deductibles must be collected the same day services are rendered.
    • If your insurance company rejects or deny your claim for services rendered, it is your responsibility to pay the remaining balance.
    • We reserve the right to charge a fee of $25.00 for last minute cancellations or no show appointment.
  • Payment options

    In addition, we are also dedicated to making top-quality care as cost-effective as possible. To assist you with your healthcare investment, we provide the following payment options:

    1. Cash --- includes personal checks.
    2. Visa/MasterCard/Amex/Discover --- we accept credit cards as payment for treatment.
    3. Care Credit--- the financing plan we offer as a separate line of credit to cover your and your family members’ healthcare needs. With CareCredit :* you enjoy these benefits:
      • Flexible financing options
      • Credit decision usually only takes a few minutes
      • No annual fees or prepayment penalties

    We are happy to provide you the above options to allow you to make convenient, low monthly payments. If CareCredit is your preferred option, you can begin any necessary treatment immediately and spread the payments out over time*.

    We are pleased you have chosen to become a member of our patient family.

    *Subject to credit approval.

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  • Acknowledgment of Receipt of Privacy Practices Notice

  • I, acknowledge that I have received a Notice of Privacy Practices from the above named practice. (Refer to Privacy Policy page)


  • If a personal representative signs this authorization on behalf of the individual, complete the following:

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  • Should be Empty: