Patient Registration Forms

Please print and complete the forms below. Then bring the completed forms to your initial appointment.

    1. Patient Registration and
      Written Financial Policy
    2. Medical History

Payment Types

We accept checks, Visa, MasterCard, Discover and CareCredit.

CareCredit is a financial plan with several repayment options, one of which is 6 months of interest-free payments. Call us for information.

Financial Policy

Payment expected at time of service.

There is a 1.5% monthly fee on balances due past 60 days.

A $40 fee will be charged to patients who “no-show” for their appointments.

Dental Insurances

We are not contracted providers with any insurance companies. However, we will submit the necessary forms for you. The reimbursement check will be sent to either you or Court Street Dental depending on the policy of your insurance company.

HIPPA Form

Coming soon.