Policies and Forms



For that portion of costs not covered by insurance, we offer several payment options:

  • Cash
  • Personal Checks
  • Credit Card – We accept MasterCard, Visa, Discover
  • Interest Free 6  and 12 month and Low Interest Extended Payment Plans offered through  CareCredit company. See our business office manager for an application or you may Click here for more  CareCredit information.

Your arrangements for financing are subject to credit approval and must be made prior to receiving your dental services.



Dental insurance is intended to cover some, but not all of the cost of your dental care. Most plans include coinsurance provisions, a deductible, and certain other expenses, which must be paid by the patient at the time of services. Reimbursement amounts are not, and never have been, a guideline for quality.

Changes in dental and medical insurance industries can leave most people confused about what they have. Many of our patients are concerned about their dental insurance and how to get the most benefit.

To obtain the most benefit from your dental insurance, it’s important for you to understand the difference between medical and dental insurance. In a lot of ways, they are completely different.

Medical insurance is designed for catastrophic events such as heart surgery, auto accidents or cancer treatment. Medical insurance normally carries high deductibles ($250-$1000) that you must pay out-of-pocket. Once met there are some co-pays to a maximum limit then the insurance covers the big bills.

Dental insurance is designed to help with treatment; however, there is no policy that pays for 100% of the dental treatment. In fact, most dental insurance policies are designed to help with basic maintenance. They carry low or no deductibles ($50-$100) but offer no coverage for catastrophic dental losses such as complete tooth loss, severe gum and bone diseases, or complete dental breakdown. The irony is when patients need dental insurance the most, dental insurance offers very little.

We will work with you to ensure that you receive the maximum benefits to which you are entitled. Please bring your insurance plan information with you on your first visit.

For more information: https://www.mouthhealthy.org/en/dental-care-concerns/paying-for-dental-care




Your health information is protected and we adhere to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) rules regarding privacy.  To download our HIPAA policy and your rights to your protected health information Click here to download HIPAA form. (NOTE: Form requires Adobe Acrobat Reader to view. Click here to download.)


Financial Policies

To download a copy of our complete Financial Policies click here. (NOTE: Form requires Adobe Acrobat Reader to view. Click here to download.)


Patient Forms

The forms below are saved in PDF format. If you are unable to open or view a form you probably don’t have adobe reader installed on your computer. To install adobe reader for free click here.

To print our Patient Registration form click here.

To print the Patient Medical History form click here.

To print the Medication Listings form click here.