For your convenience, please fill out this patient questionnaire form at home. It includes new patient information as well, so it’s a quick and convenient way to fill out these forms before you visit us! New Patient Info Payment Options We strive to offer the highest quality care at the most reasonable fees to our patients. Payment is due when services are rendered unless other financial arrangements have been made in advance of treatment. Please note that you are responsible for payment for your treatment. Payment is accepted by American Express, Visa, MasterCard, check, or cash. Payment Plans We do not compromise our patient care and are committed to providing correct treatment of the highest quality—we will always recommend what is best for your oral health. We will be more than happy to help you work with your insurance company to maximize your reimbursement for covered procedures. We will submit the insurance claim online at our office on your behalf as a convenience to our patients, in order to facilitate faster and proper compensation. Please feel free to ask our staff concerning any problems or questions that may arise. Please remember that dental insurance is a contract between you and your insurance company, largely based on the level of the premium paid by your employer. Decreased benefits are generally based on your insurance contract and do not necessarily reflect your best treatment options. You may reach us at 203-869-4755 or at firstname.lastname@example.org with any questions or concerns in regard to your initial visit. Please call if you have any questions or concerns regarding this visit. Please bring your insurance information with you to your first visit so that we can help expedite reimbursement.