New Patient Forms

HallwayClick on of the following links for a downloadable form of the relevant information:

Patient Registration

Dental Medical History

Financial Policy

Patient Special Request Form

HIPPA Form

Financial Policies

All services provided to you, your dependents, or others for whom you are responsible, you will be responsible for payment for said services. Unless insurance is available or payment is otherwise prearranged, payment is due in full at the time of treatment. If treatment is terminated or suspended prior to your treatment being completed, any fees for services already provided shall become due and payable immediately. If the account is not paid as agreed upon and is turned over to collections, you agree that an additional fee will be added to your account balance to cover the costs of collection.

Returned checks shall incur a $25 return check charge and the patient will no longer be able to pay with a personal check.

Insurance

If you have dental insurance, please provide the necessary requested insurance information to our staff in advance of your appointment. Not doing so may cause you to be required to pay in full for treatment at the beginning of your appointment. As a professional courtesy, we will attempt to verify your insurance benefits before your appointment and file your insurance claim for you upon completion of treatment.

You understand that our practice’s fees may differ from those fees allowed by your insurance carrier. You also understand that you are ultimately responsible for the full amount of treatment should your insurance company not pay the claim. All insurance claims filed on your behalf that remain unpaid after 60 days of filing shall become your immediate responsibility to pay.

We accept the following forms of dental insurance:

Medicaid NC
Delta Dental
Ameritas
Blue Cross Blue Shield
United Healthcare
United Concordia
Cigna
Aetna
Guardian
MetLife
Dentemax
Principal Financial

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