The primary focus of my dental practice is to make dental care:

Convenient
Comfortable
Affordable

The best dental care in the most unique dental office is no good if it is not affordable.

While it isn't possible to provide a modern dental office and state of the art equipment and a dedicated, caring staff for free. It is possible to make an investment in your future health with a simple call to Dental Fee Plan. I have been working with Dental Fee Plan for five years. They have been caring and professional in helping patients finance their dental care needs. Very often, a small monthly payment can help you to get the dental care you need without waiting.

Welcome to our practice Financing Form. Feel free to print out this form and bring it with you when you visit us.

* indicates a required field I would like to be addressed as:*
Email address:*
Email address 2:
First Name:
Middle Name:
Last Name:
Address:
City:
State:
Zip Code:
Home Phone:
Birthday:
State of Birth:
Social Security#:

Employer Information

Employer Name:
Employer Address:
Employer Phone:

Medical Information

Group Health Plan:
Plan Administrator:
Type of Coverage:
Identification No:
Address:
Address (cont.):

Nearest Relative

Name:
Relationship:
Address:
Home Phone:

Purpose of this Visit

Comments:

Whom may we thank for referring you to our practice?

Source:

Name of person of office who referred you?

Name:

Additional Information

Please send me regular updates from the Dr.
I prefer my correspondence in HTML format

Spouse (or other party) Personal Information

Spouse Email address:
First Name:
Middle Name:
Last Name:
Address:
City:
State:
Zip Code:
Home Phone:
Birthday:
State of Birth:
Social Security#:

Spouse (or other party) Employer Information

Employer Name:
Employer Address:
Employer Phone:

Spouse (or other party) Medical Information

Group Health Plan:
Plan Administrator:
Type of Coverage:
Identification No:
Address:
Address (cont.):