Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
This is the account guarantor and this person MUST sign when arriving at our office.
Please complete information even if you’ve presented a card to us.
Signature of Responsible Party will be needed when you visit our office.
Dental Savings Plan
Cash, Check or Credit Card at time of service.
Extended payment plan( Care Credit)
Payment in full prior to treatment: 5% discount (if over 1,000.00)