If you are a new patient to our office, the attached file contains our new patient bundle with forms that will need to be filled out when you arrive at our office. Printing them, filling them out and bringing them with you will allow us to attend to your medical needs more quickly than completing them on your arrival. Thank you and please call our office if you have any questions at all.
When booking your appointment we do require a deposit from you which is your confirmation of your commitment to attend your appointment. It will be deducted from your bill for the treatment rendered. The reason why we adopted this policy is because the Dr’s time has been allocated and is often very difficult to fill the cancelled appointment time within 48 hours notice. Your appointment is a set time period reserved especially for you. This policy also allows us to operate more efficiently and helps us keep costs low for our patients.
New Patient Forms
Download, Print Portrait layout & Complete Prior To 1st Visit
This web site uses files in Adobe Acrobat Portable Document Format (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.
In-House Dental Benefits Plan
Membership in our In-House Dental Benefits Plan is available to all patients. After payment of an annual fee, members will receive the following:
| 2 Regular Dental Check-Ups (For Non-Periodontally Involved Patients):|
- Digital X-Rays (Bite Wing X-rays once a year; panoramic or full mouth series once in 5 years.)
- Dental Cleaning
- Oral Cancer Screening
- Oral Hygiene Instruction
- Periodontal Evaluation
- Fluoride (children to age 18)
(FOR PERIODONTALLY INVOLVED PATIENTS, THERE WILL BE AN ADDITIONAL FEE OF
$50 PER CLEANING VISIT)
| 2 Emergency Visits:|
- Problem Focused Exam
- Single X-Ray (if necessary)
| 15% Discount Off Our Usual and Customary Fee:|
- A treatment plan will be provided in writing for all recommended procedures displaying the regular fee and the discounted rate.
|No Waiting Periods|
No Claim Forms
|No Restrictions on Treatment|
No Pre-Determinations Necessary
|No Age Limitations|
| || || |
|YEARLY FEE||BREAKS DOWN TO JUST|
|SINGLE PERSON||$400||$7.69 A WEEK|
|COUPLE||$725||$13.94 A WEEK|
|FAMILY OF FOUR||$1375||$26.44 A WEEK|
|ADDITONAL PERSON||$350 PER PERSON||$6.73 A WEEK|
Coverage is in effect for one benefit year. Coverage begins when membership has been paid in full. Members will be notified one month prior to membership renewal. Fees subject to change. Member will be notified prior to re-enrollment.
For your convenience, we accept cash, personal checks, money orders and major credit cards. Payment is expected at the time services are performed. When more extensive dental care is necessary, financial arrangements can be made with our office.
As a service to our patients, our practice accepts most dental insurance programs, including non-managed care, indemnity (traditional) and PPO out-of-network. We are not part of any managed care network. Our accounting staff will prepare all the necessary forms for your dental benefits. However, we remind you that your specific policy is an agreement between you and your insurance company. Please keep in mind that you are responsible for your total obligation should your insurance benefits result in less coverage than anticipated. Our staff will gladly submit a pre-treatment estimate to your insurance company so that you will know what your benefits will be.
The fees charged for services rendered to those who are insured are the usual and customary fees charged to all our patients for similar services. Your policy may base its allowances on a fixed fee schedule, which may or may not coincide with our usual fees. You should be aware that different insurance companies vary greatly in the types of coverage available. Also, some companies take care of claims promptly while others delay payment for several months.
Treatments today. Payments tomorrow.
As a service to our patients, we are pleased to suggest an option for dential health financing.
The Citi Health Card offers flexible payment plans at participating providers that allow you to get the treatments you need right now. Other benefits include:
* Flexible payment plans
* Easy to use
* Easy to manage
As a service to our patients, we are pleased to offer the CareCredit card, the nation's leading patient payment program. With CareCredit you can finance 100% of your dental care and there are no upfront costs, no annual fees, and no pre-payment penalties. So, you can begin your treatment today and conveniently pay with low, monthly payments. CareCredit offers a full range of payment plans so you can find one that works best for you. With the popular No Interest Payment Plans* there are no interest charges if you pay your balance in full within the specified time period. Monthly payments can be as low as 3% of your balance. For procedure fees from $1,000 and up, CareCredit offers 24, 36, or 48 month plan options with low monthly payments available.
CareCredit can be used by the whole family for ongoing treatment without having to reapply. And by using CareCredit for your dental care, you can save your other credit cards for household or unplanned expenses. It only takes a few minutes to apply for CareCredit and you'll receive an online decision in seconds! Apply Now or see our staff for more details.