New Patient Information

Wilson, Greenville, Goldsboro, Rocky Mount, Raleigh & nearby areas

Thank you for choosing us as your new dental home.  The following provides the basis for the financial aspect of your treatment.  We sincerely desire to treat our patients in a pleasing atmosphere and find this can best be accomplished when a clear understanding exists regarding financial arrangements.  Please contact the office at any time with questions regarding your financial responsibility.

PAYMENT:  Fees for services are due when treatment is rendered. Payment may be made in cash, check, Master Card, Visa, Discover or CareCredit.

FINANCING:  We offer financing through CareCredit.  Many options, including zero interest financing are available.

PREPAYMENT COURTESY:  For treatment plans exceeding $500.00 (excluding Hygiene), a 5% courtesy discount is given for payment IN FULL (includes insurance estimated benefit and patient's estimated part) by cash, check, Master Card, Visa or Discover at the beginning of treatment. CareCredit plans are excluded from the courtesy discount.

INSURANCE:  If you have dental insurance, we will file with your insurance provided you supply us with a current insurance card.  We will make every effort to estimate your benefits.  The patient's portion is due when services are rendered.  Although we make every effort to help you understand and obtain your benefits, we cannot guarantee your insurance provider will pay. The amount of the reimbursement is determined by the insurance carrier.  We do not accept responsibility for collecting on an insurance claim or for negotiating a settlement on a disputed claim.

THIRD PARTY PAYMENT:  If the guarantor of account is someone other than the patient, financial arrangements must be made proir to treatment being provided.

NON-PAYMENT:  In the event the charges incurred are not paid in full when due and collection action is instituted, the patient is responsible for the additional costs associated with such collection activity.  The collection costs may include and are not limited to collection agency fees, attorney fees, court costs and/or any other expenses incurred in its collection as allowable by law. 

RETURNED CHECKS:  A returned check and the processing fee of $25.00 must be paid in cash.

CANCELLATION:  Patients are expected to notify the office at least 24 hours prior to their scheduled appointment if they cannot keep the appointment.  Failure to properly notify the office may result in a charge of $50.00.

New Patient Forms:

New Patient Registration Form

HIPAA Forms:

HIPAA - page 1

HIPAA - page 2

New Patient Info