New Patient Registration
About you
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Spouse Information
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Dental Insurance

Primary Dental Insurance

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Secondary Dental Insurance

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In the event of an emergency, is there someone who lives near you that we should contact?

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Medical History
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Have you ever had any of the following disease or medical problems?

Choose YES if you do have the condition.

Are you allergic to any of the following?


Dental History

  1. DENTAL BENEFIT EXPLANATION: We will gladly file your insurance claim each time that services are rendered. Your insurance company will process the claim based on the plan you have chosen. The extent of coverage varies greatly from company to company, and sometimes even within the company. As a courtesy to out patients we try to familiarize ourselves with the latest insurance updates, however, it is ultimately your responsibility to know all exclusions, and waiting periods of your dental plan.

  2. PAYMENT IS DUE AT THE TIME OF SERVICE: We accept American Express, MasterCard, Visa, Discover, check and cash. Our office also offers an outside financing company called Care Credit that is endorsed by the American Dental Association.

  3. MISSED APPOINTMENTS: Perhaps you are not aware, but canceling an appointment on short notice you actually take up two appointment slots(the one cancelled, and the new appointment that is made) Unless cancelled at least 48 hours in advance, we reserve the right to charge for late cancellations and for missed appointments. As a courtesy, we call to remind you of your appointment several days in advance. Please remember to update all pertinent information with our office. Plese help us serve you and other patients by keeping you appointment.

  4. MINOR PATIENTS: The adult accompanying a minor and the parent (or a guardian of a minor) is responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied, unless payment has been pre-arranged.

  5. PRIVACY POLICY: Our office does not disclose information about our patients or their treatment except to the extent permitted by law. Personal information will be maintained in a confidential manner. Information Portability and Accountability Act (HIPAA). Our office routinely takes radiographs of patient's work that maybe used for instructional or demonstration purposes; the patient must notify the doctor if he/she does consent to these limited uses.

  6. I have read, understand, and agree to the terms set forth above.

    Thank you for understanding our Financial and Privacy Policies. Please let know if you have any questions and concerns.

Office Policy
In order to better serve you in the most consistent, efficient and transparent way possible, we have established the following office policies. Please place your initials by each to indicate that you have read and understood them.
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