Please download and print out the following forms which will be required for your first visit. If you have any questions regarding these forms please contact our office for assistance.
Please click on the forms above to download them to your computer
FINANCIAL POLICY
FEES
Our fees are based on the actual work provided and the time involved.
The treatment plan, including the total fee, will be presented at the initial visit.
Payment is due at the time dental treatment is provided unless prior arrangements have been made with one of our financial coordinators.
For your convenience we accept: cash, checks, Visa, and MasterCard.
We also offer personalized financial arrangements on extensive dental treatment plans. For separated or divorced parents, the parent who brings the child to the office is responsible for payment of fees charged for that child’s care. If another agrees to payment responsibility, that person must provide an
acknowledgment in writing of their desire to pay for care. It is the responsibility of the person
bringing the child to the office to obtain a written agreement and to inform the other person of care being provided.
DENTAL INSURANCE
We participate with and submit claims for some insurance companies.
Please call our office for more information.
If we do not participate with your insurance plan, our staff will assist in processing your insurance forms.
Bring a copy of the form with the top portion filled out and any explanation of benefits to the first visit.
Remember that you, not your insurance carrier, are ultimately responsible for payment of services rendered in our office.