Patient Information


Dental Insurance Information


Dental history

HIPAA Consent and Notice of Privacy Practices

Purpose of Consent: By signing this form, you consent to our use and disclosure of your protected health information to carry our treatment, payment activities and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide to sign this consent. Our notice provides a description of our treatment, payment activities, healthcare operations and of the uses and disclosures we may make of your protected health information.

I authorize the release of my dental information to:


I,have had full opportunity to read and consider the contents of this consent form and your Notice of Privacy Practices. I understand that by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.

Oral Cancer Screening

Our practice strives to provide important enhancements in oral health care for our patients. We are concerned about oral cancer and look for it in all at risk patients. One person dies every hour in the United States from oral cancer. 25% of oral cancer victims have no lifestyle risk factors.

Oral cancer risk factors include, but are not limited to people over 40 years old, tobacco use, chronic alcohol consumption and oral HPV infection.

We find that using Oral ID along with visual oral cancer examinations improves our ability to identify suspicious areas that may have been missed during the conventional examination. Early detection of pre cancerous tissue can minimize or eliminate the potentially disfiguring effects of oral cancers and possibly save your life.

Dental insurance might not cover the Oral ID exam. However, this office is happy to verify your coverage. The fee for this enhanced examination is $20

Yes. I authorize the clinician to perform the Oral ID exam along with the standard oral cancer examination. I accept financial responsibility for this enhanced exam.

No. I would prefer not to have the Oral ID exam at this time.



Your insurance is a benefit to you. As a courtesy, our staff will coordinate your dental benefits and send claim forms along with any required correspondence to your insurance carrier. The information our staff receives from your insurance carrier regarding your dental benefits is an estimate and is not guaranteed until it has been reviewed and authorized by a professional representative from your insurance carrier. Services not covered by your insurance carrier due to waiting periods, or any other reason(s) specified by your insurance carrier, are YOUR RESPONSIBILITY and are to be paid IN FULL at the time services are rendered, or upon rejection of your claim.

Dental benefits are based upon a contract made between you and your insurance company. If you have any questions regarding your dental benefits please contact your insurance company directly. Dental benefit plans will NEVER pay for all dental care expenses. It is only meant to assist you.

WE DO NOT ACCEPT SECONDARY INSURANCE due to numerous limitations placed by insurance carriers regarding coordination of benefits and several policies. Your portion is due regardless of the secondary coverage. You are responsible for submitting any claims and necessary correspondence to your secondary insurance carrier for reimbursement.


Payment is due in full at the time services are rendered. Our office accepts Visa, MasterCard, Discover, American Express, Care Credit, Debit cards, Cash and Personal checks.


Broken appointments are a significant contributor to rising healthcare costs, and we make every attempt to remind you of your upcoming appointments by E-mail, Text message, and Telephone. Please notify our office in advance (at least 24 hours prior to your scheduled appointment) if you need to cancel or reschedule your appointment(s).

Please review our office policies:

I have read and fully understand this Financial & Cancellation Agreement, and I agree to the terms listed above.