1 Patient Information
2 Dental Insurance
  • Phone Numbers
  • :
  • IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)

1 Dental History
2 Health History
  • Place a mark on "Yes" or "No" to indicate if you have had any of the following:

  • Our Dental office would like to “welcome you”! We will take the utmost care and concern for your dental needs. We have a state of the art office with a caring staff. You are very important to us and we would like to make you a part of our dental family. Please see our office policies below: Payment's Our office will always give you a treatment plan for any of your dental needs. We take Cash, and Visa, Master Charge, Discover. Financing We also have our In house financing with “Care Credit” and “Springstone” if your dental needs are beyond the cost of your insurance or if you don't have insurance. Please ask about an application at our reception area. Broken Appointments Also we schedule all appointments for our patient's and to be considerate to others we do require a confirmation call back before all appointments made and if we do not here from you within 48 hrs to confirm we do charge a fee of $25.00 for a broken/canceled appointments. Transfer's of X­rays We also take the state of the art digital x­rays and if the patient transfer's out of our office we do charge $25.00 for the x­rays. I understand the office policies that were presented to me.