Pediatric Dentist Forms and Policies

New patient forms

Prior to your first visit, you may download and complete the following forms to save you time when you arrive at our office. 

  • Dental Materials Fact Sheet 2004
  • Health History and Registration Form
  • Notice of Privacy Practice
  • Practice Guidelines
  • Appointment policies

    • Please click here or call us at 916.594.9444 to make an appointment.
    • Patient satisfaction and your time are very important to us. Every effort is made to stay on schedule so please arrive as scheduled.
    • Advanced notice of 24-48 hours is requested to cancel appointments if necessary. Without sufficient notice, we do not have the opportunity to successfully fill your child’s appointment therefore, that time remains open and it is too late to invite another child for their care.
    • A $25 fee may be charged for failed appointments and after a second cancellation when advanced notice has not been given.

    Financial policy

    • We accept most insurance plans. Insurance plans are unique and adhere to specific covered and non-covered procedures depending upon your individual plan. We do our best to provide accurate treatment and insurance estimates with the information provided us and from our initial contact with your insurance company.
    • For your convenience we will prepare Treatment Estimates in advance of dental services.
    • Treatment is recommended regardless of insurance deductibles, maximums and plan limitations.
    • In order to keep our fees to you as low as possible we ask that deductibles and co-payments be paid at the time of service. For your convenience an estimate for dental care will be prepared prior to scheduled appointments to help you avoid unexpected balances.
    • Please be advised that you are responsible for all balances not paid by your insurance company.
    • Your assistance may be necessary to receive payment from your insurance in a timely manner.

    Payment options

    • For your convenience we accept: Cash, Check, ATM/Check Card, Visa, MC, Outside Financing.
    • Interest free patient financing, CareCredit, is also available through our office to help you meet your healthcare needs. Many patients put off treatments and procedures because they cannot afford to pay. Doctors offer CareCredit payment plans as a convenient option to consumer credit cards, cash or checks. CareCredit allows you to pay over time often without incurring interest charges instead of a lump sum prior to treatment. Offering CareCredit removes the accounts receivable responsibilities from the doctor and allows them to focus on recommending and providing the best care to their patients.

    Notice of Nondiscrimination

    • Greenhaven Pediatric Dentistry complies with applicable Federal civil rights laws and does not discriminate on the basis on race, color, national origin, age, disibility, or sex.
    • Greenhaven Pediatric Dentistry does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

    Click Here to Read Full Notice of Nondiscrimination

    Contact us for more information