Patient Information
PATIENT RESPONSIBILITYPERTINENCEREFERRALREGISTRATION FORMSREQUESTING SOCIAL SECURITY NUMBERCANCELLATION POLICYTARDINESSPAYMENT POLICYINDEPENDENT FINANCINGPREPAYMENT REQUIREMENT FOR DENTAL LAB WORKDENTAL INSURANCEINSURANCE PAYS SUBSCRIBEREMERGENCY APPOINTMENTINITIAL APPOINTMENT (NON-EMERGENCY)TREATMENT PLANAPPOINTMENT ORDERAPPOINTMENT CONFIRMATIONSCHEDULE CHANGESAPPOINTMENTS FOR FAMILIESREFUSAL OF TREATMENTRECORD TRANSFER REQUESTQUESTIONSDISCLAIMERHIPAA NOTICE OF PRIVACY PRACTICESTREATMENT PLAN
A Treatment Plan is only an estimate. Actual treatment and resultant fees may be different at time of service.Fees listed on a Treatment Plan from this office will be honored for three (3) months from the date of issue.
Treatment listed on a Treatment Plan not performed prior to three (3) months from the date of issue will be subject to the fee schedule at time of service.
