Please print and fill out the appropriate form below to help expedite your visit to our practice.
New Patients please print, complete and sign items with **
We are in-network providers for Delta Dental Premiere, and BCBS of North Carolina (Eff. 12/15/2015). We accept all third
party dental insurances and gladly file claims on your behalf. Prior to each appointment we will estimate any co-pays or deductible
costs that you will pay on your dates of service. If you cannot pay that amount, please call the office to reschedule at a time when
your budget will allow it.
No Dental Insurance?
We offer an in-house dental savings plan for patients without dental insurance. This plan saves our patients approximately 70% on cleanings, exams and yearly x-rays. There are additional discounts for fillings, crowns and even additional cleanings. Please call the office (919) 488-3384 to find out more!
I acknowledge that payment in full is due at the time of treatment, unless arrangements are made prior to receiving dental treatment. Patients with insurance are required to pay any amount not anticipated to be covered by the insurance company at the time of service. Parents/ Guardians are responsible for all fees and services rendered for treatment of a minor/child. I accept full responsibility for all fees not covered by the insurance. I also agree to pay within 10 days after receipt of insurance payments any amount not paid by the insurance company. A finance charge of 1.5% per month will accrue on any unpaid balance after 60 days. Attorney fees will be charged for any accounts turned over for collections. I understand a 48 hour notice is required for appointments needing to be rescheduled or cancelled. Any cancelled, rescheduled or missed appointment without 48-hour notification is subject to a charge of $50.00 per appointment. Repeated late cancellations or missed appointments will result in our office no longer scheduling advance appointments, but only same day appointments. If you have any questions regarding any office policies, please feel free to ask a staff member. I certify that I have read and understand the information presented on this form.
- Effective January 1, 2016 – Returned/NSF check fee will be $25.00 and no further checks will be accepted.
- Effective January 1, 2016 – The senior citizen discount will only apply to patients 62 years and older who do not have dental insurance and cannot be combined with any other discounts or the dental savings plan.