Save time! New and returning patients can download these forms, then print and fill them out. Just bring them with you to our office, and it will make your visit that much quicker!
ADA codes: 0150, 0330, 0274. For a fee advertised ‘Minimum Fee Only’ or for free service: the patient and any other person responsible for payment has the right to refuse to pay, cancel payment or be reimbursed for payment for any service, examination or treatment which is performed as a result of and within 72 hours of responding to the advertisement for the free, discounted fee, or reduced fee service, examination or treatment.