Pre-Registration

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Welcome to our Family of Patients!

Please fill out this form completely. The better we communicate, the better we can care for you.

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About You

Your information will be sent over a secure connection and kept confidential.

Dental Insurance

If you have dental insurance, please bring your insurance card with you to your appointment.

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Dental History
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Esthetic Analysis

This information is used to develop a complete picture of our patients needs and desires. There are many new techniques and materials available for Smile Design and Enhancement. This information will enable us to discuss options available to you.

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Financial Policy

All fees are due and payable at the time of service unless other arrangements have previously been made.

All payments are the responsibility of the patient regardless of insurance or any other third-party involvement.

A 2% finance charge will be applied to all delinquent balances over 30 days old.

Any treatment plan can receive a 5% DISCOUNT when paid in full by cash or check on the day of services.

We accept Visa, Mastercard, American Express, Discover, Care Credit, and Capitol One Healthcare Financing.

We will accept most dental insurances and will be happy to file claims for you. Any and all non-covered services are the responsibility of the patient and will be billed directly to the patient. Some out of network insurances may require patient payment at the time of service.

eSignatures

Checking the following boxes is a legally binding way of signing this form electronically.


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Our office is committed to meeting or exceeding the Standards of Infection Control mandated by OSHA, the CDC and the ADA.