New Patient Forms
Click on of the following links for a downloadable form of the relevant information:
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.
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:
Blue Cross Blue Shield