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We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. lf you have questions we'll be glad to help you. We look forward to working with you in maintaining your dental health.
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Patient Information
Dental Benefits
Consent for Services
I authorize payment directly to this dental office. I understand that I am responsible for all costs of dental treatment. I authorize this dental office to administer medications and perform such diagnostic, photographic, and therapeutic procedures that may be necessary for proper dental care. The information on this page and medical/dental history are correct to the best of my knowledge. I grant the right to this practice to release my medical/dental history and other information about my dental treatment to third party payers and/or health professionals. I consent and agree to the use, reproduction, or otherwise published photograph of me in any publication, social media, website or presentation by the doctor. The doctor or persons authorized by the doctor have the right to use such images in any advertising and promotion of such publication and the dispositions of all rights thereto.
Financial Guidelines
Payment is due at the time service is rendered. If a procedure requires multiple appointments, payment is required in full at the first appointment.

Payment options:

1. Cash
2. Check
3. MasterCard
4. Visa
5. Novus/Discover
6. American Express
7. CareCredit interest free financing

Patient with insurance: The patient is responsible for the ESTIMATED out-of-pocket portion, procedures and/or deductibles at the time of service. If the insurance company does not pay after 60 days, we will bill you directly for the full balance. For some insurances plans, payment in full is due at the time of service and patient receives insurance check.

Parents not accompanying their child to an appointment must make PRIOR arrangements for payment. Parents accompanying their children are financially responsible for payment.

18% annual (1.5% monthly) interest is charged for any unpaid balance until the balance is paid in full. If the account is in default and this account is turned over for collections, then the patient/responsible party promises and agrees to pay all collection costs including attorney fees of 33.3% of the principal balance as well as interest accrued during collections.
HIPAA Release Consent Form
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and healthcare operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The patient understands that:

*Protected health information may be disclosed or used for treatment, payment or healthcare operations
*The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this notice
* The Practice reserves the right to change the Notice of Privacy Practices
* The Patient has the right to restrict the use of their information, but the Practice does not have to agree to those restrictions
* The Patient may revoke this Consent in writing at any time and all future disclosures will then cease
* The Practice may condition treatment upon execution of this Consent

We keep a copy of our Notice of Privacy Practices for viewing and can provide you with a copy if you wish. If you would like a copy let our staff know and we are more than happy to provide you with one.
Medical History
Dental History/Questionnaire