It is our intent to make your dental visit as easy and timely as possible. The following links give you access to the general dental forms which you can fill in the comfort of your house, prior to the visit in our dental office. Please, take a few minutes to fill out the forms as much as you can and bring them in to your visit. If you have questions we will be glad to help you
Patient Information – This is the General Information and Dental Medical History form that our new patients need to fill out.
Oral Health Risk Factors – This is the Oral Health Risk Factors Evaluation developed by LED Dental, the makers of Velscope.
Treatment Authorization – This form outlines the financial arrangements and dental insurance
Notice of Privacy – Health Insurance Portability Act (HIPAA) Form
Authorization of Release – This form allows us to release your dental information to your dental insurance company.
Teeth Whitening Instructions – These are the user instructions for our patients enrolled in “Whitening for Life” program.
Click on the link to view the document. Adobe Acrobat Reader is required to view the .PDF documents. If you do not have Adobe Acrobat Reader installed on your computer, you can download it free.
If you have dental insurance, as a courtesy to you, we will prepare and submit a claim for all the services rendered and we will accept assignment of benefit payments from your insurance carrier. This will reduce your immediate, out-of-pocket expenditures. Our office will provide your insurance company with necessary documents and X-rays at no extra charge. Our office accepts cash, checks, and debit or credit cards, including MasterCard, Visa, and Discover.
Flexible, Low or No Interest Financing
For patients interested in extended payment plans, we offer flexible, low or no interest financing through CareCredit – a trusted name in patient financing. CareCredit offers no-interest and extended payment plans to qualified applicants. To apply for CareCredit, please contact our office at (719) 272-9009
We are proud and excited to introduce you to our new program: “Whitening for Life”. Learn more about our Teeth Whitening program here.