New Patient Info & Oral Appliance Referral Form
New Patient Information
Prior to your first appointment please download, print, and fill out our Patient Registration and Medical History Forms:
Once you have completed the forms, please FAX (949-640-0333) or scan and e-mail them to us at: firstname.lastname@example.org
If you do not have access to a FAX machine or scanner, it is imperative you bring the Completed Forms with you on your first visit.
The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.
Obtaining dental treatment is very important for your overall health, but using dental insurance can be confusing. Our financial policies are designed to help patients maximize their insurance plan benefits, and make filing claims easy.
Payment is due on the day of treatment.
This office will file insurance claims for you. We are happy to help you by submitting insurance claims without charge. However, our office does not guarantee payment or coverage by your insurance company. Dental insurance usually pays only a portion of your charges and we urge you to be fully aware of the provisions of your dental plan’s policy.
Cash, Check, VISA, Mastercard, or American Express are acceptable methods of payment.
In the event you are unable to make payment by any of the methods outlined above, you can ask for information about third-party lending institutions to assist you in paying for your dental treatment.
Since time with our patients is very precious, and lost time is irretrievable, we must charge for broken appointments when we have not been notified at least 48 hours in advance. Our charge for broken appointments is $80. Our desire is never to find it necessary to make this charge. Please keep your appointment. We are waiting for you.