You may preregister with our office by filling out our secure online Patient Registration Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information.
On your first visit to our office, we will have your completed form available for your signature. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.
Failure to complete the Dental Insurance section, in detail, results in self-pay.
Online Patient Registration Form
Notice of Privacy Practices
We accept the CareCredit healthcare credit card for dental procedures.
CareCredit is the healthcare credit card exclusively designed to finance healthcare services like dental care and orthodontics for you and your family. CareCredit offers special financing on purchases of $200 or more for healthcare procedures not commonly covered by insurance, including dental treatments. Plus you can use your CareCredit card over and over for follow-up appointments.
We now accept Lending Club as a financing options for our patients.
Moving forward with treatment just got a whole lot easier. Schedule treatment without delay and fit the cost into your monthly budget with a responsible payment plan offered through Lending Club Patient Solutions.
Office Financial Policy
Basic Policy: Payment for services rendered is due in full at the time of service. Our office accepts cash, personal checks, and credit cards. For any delinquent accounts, a collection charge of 50% will be added to the balance.
Check Acceptance Policy: We accept personal checks with a valid picture ID. If you choose to pay by check and your check is dishonored, you agree to pay a processing fee of $40, or any higher amount allowed by law, and we may electronically debit or draft your account for this fee. Also, if your check is returned for insufficient or uncollected funds, your check may be electronically re-presented for payment.
For Patients With Insurance: As a service to our patients, we will accept “assignment of benefits” and will bill your insurance carrier, provided proper information is provided to us in advance. Every effort will be made to closely estimate your co-payments and deductibles, which are due at the time of service, but ultimate responsibility for the unpaid balance rests on you. Please understand that insurance is a contract between you and your insurance company. If an insurance carrier has not paid within 60 days of billing, any unpaid professional fees are due and payable in full from you. Any service provided that is under $300.00 must be paid at the time of service. In cases where we accept “assignment of benefits,” we will require a 30% down payment.
Managed Care Participants: Some benefit plans require pre-authorization and specialist referral forms from your primary physician. Please provide the proper insurance plan identification and forms necessary prior to your visit. All co-payments or patient out-of-pocket fees are due and payable at the time of service.
Cancellation Of Appointments: Our goal is to provide high quality care at a reasonable cost to our patients. In fairness to other patients, and the doctor, we require at least 24 hours notice when canceling an appointment. There is a $40.00 fee for missed appointments without 24-hour notification, which will be due and payable from you. The practice reserves the right to dismiss patients with excessive cancelled appointments.