13802 W Camino del Sol Suite #101
Sun City West, AZ 85375

(623) 583-0151

New Patient Form

Welcome to our office. We sincerely appreciate you choosing our office for your dental care needs. Please be assured that we will work hard to continually earn the trust you have placed in us. In order for us to serve you better, please take several minutes to complete this information as thoroughly as possible.

Patient Information

Dental Insurance Information

Secondary Dental Insurance

Treatment Estimates

We strive to give you an accurate estimate of the total investment for the recommended treatment. Occasionally additional treatment may be recommended based on a change in your dental condition or on other unforeseen factors. If additional treatment is necessary, we will inform you at the time it becomes apparent so that you can make an appropriate decision. Payment for additional services rendered will be due at the time of treatment.

Payment Options

For your convenience, we accept cash, checks, Visa, Discover, MasterCard and American Express. We also have Care Credit financing available with both interest free, and extended payment plans.

Appointment Changes

We ask that you give us 48-hour notice in the event you need to change your appointment. This gives us the opportunity to offer your appointment time to another patient in need (dental emergencies). We appreciate this courtesy because the emergency patient waiting to schedule could be you in the future.

A fee of $50 per hour, for scheduled treatment will be charged for MISSED or CANCELED appointments without a 48-hour notice.