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NEW PATIENT FORM

Please take a minute to print and fill out the patient information form before your first appointment:

Please answer the following questions to help us to better care for your dental needs. All information will be confidential and is for our records only.

Sex

Medical History

Have you been hospitalized in the last 12 months?
Women only – Are You Pregnant?
Please check all of the conditions that you have now or have had in the past

OFFICE POLICY REGARDING DENTAL PLANS

As a courtesy and convenience to you, our patient, Valley Smiles Dental Clinic accepts dental plans upon confirmation of your coverage and the information your insurance company discloses. Based on this information, we are able to provide you with estimates of treatment required to the best of our knowledge.

Your dental policy is a contract between you, your employer, and your insurance company. Should your coverage terminate or change in any way, we can only be notified of this by YOU, the patient. If treatment is not paid by your dental plan, it is the sole responsibility of you, the patient, to cover all costs.

We bill all treatment done on the day the service is rendered. If we have not received payment from your insurance company within 60 days of services rendered, then this claim becomes your responsibility. Any portion of any claim submitted to your insurance company that is not paid in a timely manner will become your responsibility.

Payment for services rendered is expected in full upon us notifying you by phone, email, or mail. Should payment not be made, Valley Smiles Dental Clinic may exercise the right to transfer your account to a Debt Collection Agency.

OFFICE rescheduling policy:

Our office kindly requests 2 full business days' notice for an appointment change. A missed appointment fee of $100 will be charged if insufficient notice is provided. Some appointments over 1 hour may require a deposit (treatment dependent). All meetings scheduled within 24hrs will be considered confirmed at the time of booking. We offer an automated reminder service to ensure you are notified and reminded of all appointments scheduled with us.

Thanks for submitting!

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