Please print these forms out and bring the completed forms to your appointment.
Please Read:
Please Fill Out:
White vs. Composite Fillings PDF
Acknowledgement of Receipt of HIPAA Notice of Privacy Practices PDF
Patient Responsibility Agreement PDF
HIPAA
Acknowledgement of Receipt of HIPPA Notice of Privacy Practices PDF
Insurance Information
We accept most PPO Insurance Plans. NO HMO / DMO PLANS.
Forms of Payment/Plans
Cash / Check / MasterCard / Visa / American Express / Discover
Automatic Monthly Billing to your MasterCard, Visa, Amex, Discover.
Monthly (no interest) Payment Plans are also available
Uninsured Senior’s Discount
We offer a 10% discount for uninsured senior citizens (65 and older) on cleaning and exams only.