New Patient Online Form

We will file all necessary forms and reports to your insurance company. We do not render our services on the basis that the insurance company pay our fee. The patient/patient's guardian is personally responsible for any fee the insurance company does not cover.

CANCELLATION POLICY: There will be a charge for any appointments missed without 24 hour notice. I understand that I will be responsible for this charge. PAYMENT POLICY: Payment must be made at the time services are rendered unless prior arrangements are made. I understand that I am ultimately responsible for the balance on my account. If I fail to meet the requirements, I know this matter will be turned over to an outside collection agency and legal charges may be filed against me. CONSENT TO TREATMENT: I authorize Dr. Blaess and her staff to perform procedures including, but not limited to prophylaxis (cleaning), taking X-Ray and photographs, administering anesthetics and/or medications, restoring (filing) teeth, removing teeth, endodontics (root canal) treatment and other procedures he/she may deem necessary for my/my child's proper care. To the best of my knowledge all the above answers are true and correct. If any of the information changes I will inform the dentist at my next visit.