Welcome!
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New Patient Welcome
We welcome the opportunity to be of service to you and your family. To best serve your dental health needs, we wish to acquaint you with our office policies.
APPOINTMENTS:
Once an appointment is made, please remember this time has been reserved for you. A minimum charge of $200 will be made for failed or cancelled appointments without prior notification of 48 hours.
INSURANCE:
An insurance policy is an agreement between the patient and the insurance company. The patient is responsible for payment of all fees. We do not render our services on the basis that the Insurance Company will pay all our fees. Most insurance companies pay only a portion of the dental investment. Although we are happy to file the necessary forms to see that you receive the full benefits of your coverage, we make no guarantee of any estimated coverage. We will file primary insurance, and secondary insurance when patient provides EOB. All insurance co-payments and payments of services not covered by insurance are due and payable at each visit.
For treatments requiring multiple appointments, such as crowns, inlays, onlays, veneers, dentures and root canals, payment is due at first visit.
COURTESY:
For your convenience we offer the following payment options:
1. Cash (2% discount)
2. Personal Checks (with driver’s license) (2% discount)
3. Credit Cards (Mastercard, VISA, Discover or AMEX)
4. Care Credit (extended payment plan if qualified)
5. Springstone (extended payment plan if qualified)
If at anytime you have questions regarding any treatment or service, please discuss them with us promptly and frankly. We will make every effort to address your concerns.
Dental Health History
Health Conditions
For the following questions, select Yes or No. Your answers are for our records only and will be confidential. Please note that during your initial visit you will be asked some questions about your response. Our team may ask additional questions concerning your health
Female Patients
Other Medical Conditions
Are you allergic or have you had a reaction to:
Diet
Headaches, TMJ pain
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IN OFFICE USE ONLY
Sleep Assessment Form
Your doctor is requesting that you complete this Sleep Assessment Form. This form determines the need for you to have a user friendly home sleep test, which will test to see if you have a challenge breathing when you are sleeping. How you breathe can affect your quality of life and especially your cardiovascular health; and can be easily treated.
Sleep Questionnaire
If the answer is YES to the all of the above questions, PLEASE STOP. and submit the form.
If your answer is NO to any of the above questions, please continue to the following questions:
Sleepiness Scale
How likely are you to doze off while doing the following activities? Please use the following scale:
0 = never
1 = slight
2 = moderate
3 = high
Part 1
Part 2
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IN OFFICE USE ONLY