Patient Forms

Find All The Patient Forms You May Need For Your Next Dental Procedure

Patient Forms
Please fill out these forms so we can expedite your first visit:

 


Financial Agreement

Payment IN FULL is due at the time of the service. As a courtesy, we will file your primary insurance. The estimated portion of the uncovered fees is due in full at the time of service; the balance after payment from your insurance company is due by the patient. If for any reason payment is not made in 90 days a service charge will be added and the family account will be sent to collections.

Confirmation Agreement

In order to be considerate of all of our patient's time and provide the quality dental care you desire, we have set forth the following agreement. We will email you 4 days prior to the scheduled appointment. If you don't respond to the email then a text will be sent a minimum of two days prior to your scheduled appointment for confirmation. Your appointment is only considered confirmed when you communicate directly with our office via email, text or phone. If we have not received confirmation from you within 24 hours of the scheduled appointment, we will no longer reserve this time for you. Upon your request, we will call again the day before your confirmed appointment as a second reminder.

Cancellation Agreement

We require a 24-hour notice in order to cancel an appointment without your account reflecting a charge for the visit. We reserve the right to charge your account for any confirmed appointment that is cancelled without a 24-hour notice. There will be a charge of $25.00 for every hour scheduled. Payment for this will be due in full at the patient's next visit.

Late Agreement

Any patient who arrives more than ten minutes late for a confirmed appointment will not be seen. This appointment will be rescheduled for another date and time to allow us to provide the standard of care we pride ourselves in! Your timely arrival allows us to stay on schedule for your appointment as well as the following appointments for this day. We strive to seat our patients and begin work at the scheduled time. Your help in this effort is greatly appreciated.