Please mark all current or historical medical conditions that apply to you (patient).
If you would like to change your statement preference, please contact the office.
Please Note: Returned checks will be subject to additional fees. In the case it becomes necessary for our office to enlist a collection service and/or legal assistance; you will be responsible for any collection and/or legal charges up to 35%.
Do You Have Insurance?
We thank you for the opportunity to serve your dental health care needs and welcome any questions you may have concerning your care or our financial policy.