How to Fill Out Our Forms:

Use the button below this form to open it, from there you can print it and fill out by hand or do it digitally. If done digitally, fill out the form, then click the print button in the upper right hand of your screen. You can either print as normal and bring it into our office, or change it to “Print as PDF” and email the document to us!


Currently, we are in-network providers for:
  • Dental Blue from Blue Cross
  • Delta Dental Premier
  • Delta Dental PPO plus Premier
  • We also accept CareCredit and provide all required documentation to qualify dental expenditures out of your FSA (Flexible Spending Account).

For all other insurances, we expect payment from you at the time of your visit and we will submit all claims on your behalf for reimbursement directly to you.