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  • New Patient Form

  • Demographics

  • Dental Benefits

  • Dental History

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  • Medical History

  • Fluoride

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  • Office Policies

  • Payment Options

  • We accept cash, personal checks, Visa, Mastercard, American Express, Discover, and Care Credit. Please note that we do not carry change for cash or non-exact payments. If you pay an amount exceeding what you owe in cash, we will keep the extra as a credit on your account for future use. We offer several outside financing companies that will allow you to make a comfortable monthly payment.

  • Insurance

  • We will bill all insurance plans as a courtesy, regardless of network participation status. Insurance information must be provided to the office before the day of the scheduled appointment. If the patient does not give sufficient time to verify the dental benefits, the full office fee will be collected until the office can verify the plan information.

    If the office or provider is out of network with the insurance and the policy does not accept the assignment of benefits, payment in full is due at the time of service for the office's full fee. Proof of insurance must be provided when the insurance is added to the account. Payments for estimated patient portions and/or deductibles are due at the time of service. Should there be any balance left after the insurance payment is received, it will be billed to the patient.

    As a courtesy, we will appeal an unjustified insurance denial for services up to two times on the patient's behalf. If, after two appeals, the insurance claim has not been paid, the balance will be reassigned to the patient.

  • Finance Charges

  • A statement will be generated monthly for account balances and delivered to the billing address on file. After three statements or 120 days, unpaid accounts will be forwarded to an outside collection agency, at which point we will no longer accept payment. Accounts sent to collections will be dismissed from the practice.

    Checks returned to the office from your financial institution are subject to a $50 returned check fee.

  • Minors

  • If minors are not receiving diagnostic or preventative services, a parent or legal guardian must accompany the minor patient to the appointment. Treatment consent can only be signed by the minor patient's legal guardian; no exceptions will be made. Estimated patient portions will be the responsibility of the accompanying guardian and are due at the time of service.

  • Appointments

  • We require a 48 business-hour cancellation notice and rescheduling for all appointments.

    Accounts with cancellations or changes made within 48 business hours of the reserved appointments will be assessed a fee of $75 for a Hygienist and $150 for a doctor per reserved hour. We will text and email to attempt to remind you of your reserved appointment, and we offer electronic appointment reminders for your convenience. Please note that our office is closed Friday through Sunday.

    Reserved appointments must be confirmed 24 business hours before the scheduled time, or they will be forfeited. We will call, text, and email to attempt to confirm the appointment before it is removed from the schedule. We offer electronic appointment reminders and confirmations for your convenience.

    No-show appointments will be assessed a fee of $50 per reserved hour. After two late cancellations or no-shows, the patient must pay a $100 reservation fee before scheduling further appointments. If an appointment fails or is canceled within 48 business hours, the reservation fee will be forfeited, and the process will start again. After two reservation fee forfeits, the patient will be dismissed from the practice. The reservation fee will be returned to the patient after 12 consecutive months of no failed or late canceled appointments.

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