Request an Appointment

Appointment For *

New Patient Exam/ Consult

Check-Up

Emergency

Treatment

Adult/ Parent/ Legal Guardian Name *

First Name

Last Name

Adult/ Parent/ Legal Guardian Date of Birth *

MM

DD

YYYY

Your Phone # *

(###)

###

####

Your Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Adult/ Parent/ Legal Guardian Name (2)

Complete if adding another adult.

First Name

Last Name

Adult/ Parent/ Legal Guardian Date of Birth (2)

Complete if adding another adult.

MM

DD

YYYY

Child Name (1)

First Name

Last Name

Child Date of Birth (1)

MM

DD

YYYY

Child Name (2)

First Name

Last Name

Child Date of Birth (2)

MM

DD

YYYY

Child Name (3)

First Name

Last Name

Child Date of Birth (3)

MM

DD

YYYY

Do you have a PPO Insurance Plan with Out-of-Network coverage? (If yes, all the insurance questions below must be completely filled out.) *

Yes

No

Insurance Subscriber Name

First Name

Last Name

Insurance Subscriber Date of Birth

MM

DD

YYYY

Credit Card Authorization *

Providing credit card information authorizes payment for services. A 3.5% processing fee applies to all credit card transactions. Thank you.

I Acknowledge

Payment Processing and Authorization *

To ensure smooth and timely payment processing, we require a credit card on file. By providing your credit card information, you authorize us to charge your card for any insurance copays or outstanding balances. If you prefer to pay by cash or check, please indicate this in the 'Additional Information' section of your forms. You may bring cash or check to your appointment, but a card will still remain on file for your convenience. Thank you for your cooperation!

I Acknowledge

Appointment Change Policy *

There is a fee of $125 for all Appointment changes within 48 hours of scheduled appointments.

I Acknowledge

Out-of-Network Practice Acknowledgment *

We are Out-of-Network with all insurance companies. Most PPO dental insurance plans include out-of-network benefits, generally providing 50-100% coverage. While we may attempt to verify your insurance benefits based on the information you provide, please note that any details received from your insurance company are not a guarantee of benefits. We recommend reaching out to your insurance provider to confirm the Out-of-Network benefits of your plan and to inquire about the percentage of coverage for services rendered. To streamline the payment process, we collect full payment at the time of the visit, aligning with the common practice for out-of-network specialists. Following the payment, we will supply you with a receipt showing services rendered and your payment. You can then submit this receipt to your insurance company, and they will reimburse you directly based on the terms of your contract with them.

I Acknowledge