FORMS
Please print and fill out these forms prior to your first appointment with us. Then, bring them to our office on the day of your appointment. We look forward to seeing you soon! 

HIPAA Release form 

Authorization for Release of Information Form

Missed Appointment Form

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Download
Download

Patient Medical History Form

Notice of Privacy Practices 

New Patient Registration Form

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Download
Download
You do NOT need to print the "Notice of Privacy Practices" document. This document is for your review and understanding only. Please take the time to read this document, and if you have any questions feel free to contact our office. 
PAYMENT

Payment Methods

We expect payment for services on the date of your appointment.  We are not a preferred provider with any insurance company; however, if you have dental insurance, we will gladly file for your claim as a courtesy.  It is your responsibility to check with your provider about individual benefits.  We expect your portion of payment at the time services are rendered.  If your insurance pays you, we need to be aware of this so that arrangements can be made to accommodate.  Please let us know if you have any questions or concerns regarding payment prior to your appointment.

We accept the following:

Cash
Check
Money Order
Care Credit Financing

Cancellation Policy

We ask that you provide us with at least a 24 hour notice for a change or cancellation of an appointment.  We reserve the right to charge a $30.00 fee for missed appointments without adequate notice, as your time slot is reserved exclusively for you.  After 3 missed appointments without adequate notice, we reserve the right to ask that you find an office with more convenient hours for you and may dismiss you from our practice.