Patient Forms
Please click the link below to complete and submit our forms electronically, so we can expedite your visit. We do not accept paper forms and permit forms to be completed on site.
What To Expect
All patients are asked to arrive 15 minutes prior to their scheduled appointment to allow for insurance verification/presentation, forms completion, and registration. We do not offer a grace period or late courtesy. The first appointment consists of a meet and greet with dentist and team, comprehensive exam, radiographs, cleaning and treatment plan presentation. Patients are expected to bring their insurance card and government issued identification to their initial appointment. Please note, that we do not accept the radiographs of other offices; therefore, you may have an out-of-pocket fee, if your insurance carrier determines you are ineligible for new radiographs. In addition, we are a fluoride-based practice. Fluoride is a natural element proven to prevent cavities, demineralize early cavities, desensitize teeth and more. All of our products used contain fluoride. You may have an out of pocket expense for fluoride when using insurance to pay for treatment.
Financial Policy
As a condition of treatment within Dimples Dental Suite, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment. Before any dental treatment begins, the patient and/or responsible party will receive a consultation regarding that appointment's treatment and costs. We attempt to keep our fees as low as possible while still providing quality care in our office. Prompt payments enable us to keep administrative costs associated with billing and collection efforts lower for everyone. Actual treatment costs are based on the Dimples Dental Suite or Insurance Carrier Fee Schedule, whichever is better, that are in effect when a procedure is started. We accept Cash, Certified Check, American Express, Discover, VISA, and MasterCard for payment. For procedures that take multiple appointments to complete, payment may be split up over a number of appointments required with a deposit. Should you require monthly installments, please consult our dental team. We offer financing options with CareCredit, LendingClub, LendingPoint and ClearGage. Only written agreements/arrangements are honored. Any fee estimates for dental care can only be extended for a period of six months from the date of the patient examination. In consideration for the professional services rendered by the practice, patient must agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. In addition, patients will have to agree that the charges for services shall be as billed unless objected to, in writing, within the time payment is due.
Insurance Policy
As a courtesy to our patients with dental insurance, we currently accept, we will file your insurance claim and allow you to pay only your deductible and/or co-payment as services are rendered. You will be expected to assign payment of insurance benefits to the doctor for treatment. Any payments received by the doctor from your insurance company will be credited to your account, or refunded to you, if you have paid the dental fees incurred. When the reimbursement check is required to be sent to you and the insurance company is unwilling to pay us directly, we ask that you pay the full balance the day the services are rendered, and we will file your insurance for you. Please remember that the contract is between you and your insurance company and your total balance in our office is always your responsibility. We make every effort to give you an accurate estimate of what your portion of our fees will be based on the information provided to us from you and your dental insurance provider. Should the actual payment from your insurance company be different than originally estimated, you will be billed or credited according to the status of your overall account. Any dispute regarding reimbursement or the amount of reimbursement is between you and your insurance carrier. We strongly advise you to familiarize yourself with any restrictions and all details associated with your insurance policy prior to initiating treatment.
Past Due Accounts Policy
Account aging begins the day your charges are incurred and a late fee of $10.00 per month on the unpaid balance will be charged on all accounts exceeding 60 (sixty) days, unless previously written financial arrangements are satisfied. Again, in an effort to keep administrative costs associated with billing and collection efforts low, we require a credit/debit card to be on file to pay balance(s) due or issue refunds. Your credit/debit card will be charged or credited upon completion of services or receipt of explanation of benefits from your insurance carrier and a statement of services will be emailed and/or mailed to the address on file. If your credit card is denied, we will make multiple attempts to charge or credit the card on file until payment or refund is issued. If you wish to remove your credit/debit card on file (cancel future debits or credits), all requests must be in writing (electronic mail or certified mail).
Accounts that are 120 (one hundred twenty) days past due shall be turned over to a third-party collection agency or small claims. We require a social security number to be on file, in case collections is necessary. This action will result in an additional fee of 45% of your unpaid balance being added to your account (including late fees). We will do so only if all other efforts to collect your unpaid balance within 120 days have failed. In addition, if your account is sent to a third-party collection agency or small claims, you will be responsible for the additional costs not limited to court costs and attorney fees.
Appointment Cancellation/No Show-No Call Policy
When you reserve a time with us please make every attempt to make your appointment. We do not "double book" as many offices do. This time is set aside specifically for you. You will receive an email, phone call or text message reminding you of your appointment 24 to 48 hours prior to your appointment. When you receive this message, please call, text or email us to confirm the time that you have already reserved with us. If we have not heard back from you by the close of business (5pm) the day prior to your reserved time, we will take your appointment off of our schedule. We have a 1-BUSINESS DAY cancellation policy. If you need to change or reschedule your reserved time with us, please give us at least a 1-BUSINESS DAY notice so that we will be able to fill this time with others waiting for treatment. If your appointment time with us is on Monday, please confirm with us by Friday, etc. If you cancel, fail to show for your confirmed appointment, or you arrive excessively late and treatment cannot be completed as planned, we recover our lost opportunity and associated costs for having our staff on standby with a Broken Appointment Fee of $50.00. This may sound harsh, but please understand that if you have THREE broken appointments, we reserve the right to release you as a patient and ask that you seek treatment at another Dental Practice. Thank you for understanding this policy.
Late Arrival Policy
We do not have a grace period. Please plan to arrive 15 minutes early. If you are over 15 minutes late for your appointment, we reserve the right to reschedule your appointment for a later time. The Broken Appointment Fee of $50.00 will apply to this as well. Please understand that we strive to stay on time for your appointment as well as those patients that follow you.
Arrival with Election Not to Have Services Rendered Policy
We do not "double book" as many offices do; therefore, time was set aside specifically for you. If you elect not to receive treatment upon arrival and/or placement in treatment room, the Broken/Late Arrival/Cancellation Appointment Fee of $50.00 will apply.
Records/Statements Request Policy
All requests related to patient records, radiographs, and account statements, must be submitted in writing via snail mail or email ([email protected]). You will receive an email (written) confirmation of receipt of your request. We will do our best to honor your request rapidly; however, please allow up to 14 business days from request receipt confirmation to process your request. For your security, we will only send requested items via secure email or to the mailing address on file for you.