Patient Forms

For your convenience, we have provided a printable PDF copy of our new patient registration and consent forms.

 

Patient Consent Form.                       

Patient Registration Form (English)   

Patient Registration Form (Spanish)  

(PDFs document requires Acrobat Reader.)

 

 

Payment Options

For your convenience we accept all major credit cards. We deliver the finest care at the most reasonable cost to our patients, therefore payment is due at the time service is rendered unless other arrangements have been made in advance. If you have questions regarding your account, please contact us at 617.262.1422. Many times, a simple telephone call will clear any misunderstandings.

We will work closely with you and your insurance company to maximize your benefits. However, please remember you are fully responsible for all fees charged by this office regardless of your insurance coverage.

Learn About Our Reward Program and Earn Credits Towards Your Account.

Our referral program is simple. Ask your friends to give us your name when they complete their first appointment. You can earn up to $35 credit per individual or a $100 per Family with Children through our online referral promotion. Give the gift of a healthy smile! Our promotions and Patient Appreciation E-Gifts are a great way to send a little loving reminder out there. It will cost you nothing but will give you credit and BIG SAVINGS in return. From Invisible Braces to Whitening you never know what we'll throw out there for our clients.

Coupons and Rewards are in the form of credit and are good only for purchases or credits towards patient payments on bearer or referee accounts. Credits are non transferable and have no cash value, redeemable only for services or purchases and not valid with other promotions from products represented or otherwise discounted for the purpose of limited time offers and other promotions. Not applicable to services not rendered to completion or to insurance portions of coverage. Your Insurance reserves the right to deny, partially pay or even collect on deductibles or copayments as applicable by your Insurance Service Agreement and rules of enrollment.

Referral credits are applicable to existing accounts only, they have no cash value and are redeemable for services or purchases through our practice only. Not applicable for online purchases. Delivery and or taxes are applicable to purchases or services obtained through our reward program. Insurance co-payments and other fees are applicable and not subject to discount unless allowed by your insurance contract. Insurance contract information may be obtained through your employer or directly from the insurance. Your reward credits have no cumulative limitations or expiration date, they are not transferable and may not be used in conjunction with any other specials or discount promotions offered by a manufacturer, our practice or corporations our practice conducts business with.