New Patient Dental Forms

At Glassboro Dentistry, our skilled and talented dental team works together to give your smile the special care it deserves. Our professional dental staff is dedicated to making each visit to our office comfortable and enjoyable.

In order to make your first appointment as smooth and efficient as possible, we offer all patients the opportunity to complete their new patient dental forms prior to their first appointment. It’s simple, fast, and easy! Please note: if the patient is under 18 years of age, new patient dental forms must be completed by a parent or guardian.

Call us today at (856) 956-3625 today to schedule your appointment and get to know our wonderful team!

New Dental Patient Process

Please plan to arrive 10 minutes early for your first office visit. Bring the following with you:

• Completed New Patient Dental Forms (click on links to the right to print)
• Insurance card
• Picture ID, such as Driver’s License
• All your medications (or a list), including any vitamins or supplements you take regularly
• Name, phone number, and fax number of your previous physician

Payment is due at the time of service. We accept cash, credit card, or debit card.

New Patient Dental Forms

Please click on each form to print.  Then, complete the new patient dental forms and bring them with you to your first appointment for processing.

    PATIENT INFORMATION

Fill out basic information about yourself to set up your account.

    MEDICAL / DENTAL HISTORY

Tell us about your health status so we can provide proper care.

    NOTICE OF PRIVACY POLICY

Accept our privacy policy and HIPAA stance.

    FINANCIAL RESPONSIBILITY

Accept our payment terms and conditions.

    [ DOWNLOAD PATIENT PACK ]

Dental Patient Information

Please plan to arrive promptly for your appointment as a courtesy to other patients and staff.

Please be respectful of other patients and the doctor by providing a 24-hour notice if you plan to cancel your appointment.

Most dental insurance will not cover all of your treatment; however, Glassboro Dentistry coordinators alway work to maximize your dental benefits. We ask that each patient bring the proper insurance form(s) at each visit, and that the patient information portion of the insurance form be filled out completely in advance of the visit. Please present the completed forms to the front desk team member, after signing in, upon your arrival at the office.

Our office policy for dental insurance requires that the patient, once his/her coverage has been verified by our business office team, pay for at least that estimated portion of the treatment not covered by insurance carriers on the day that the treatment is rendered. Any services provided which are not covered under your insurance plan must be paid in full at the time of your visit or upon notice of insurance claim denial.

We are happy to help you if you need assistance in understanding your dental insurance benefits and coverage. Please do not hesitate to consult our business office team. They will make certain that you are able to receive the maximum allowable benefit from your insurance in the resolution of your dental needs.

If you are unsure about your dental benefits please call us for a FREE Benefits Review and Eligibility.

In an effort to increase access to dental health care, Glassboro Dentistry offers flexible payment options. We accept all major credits, personal checks and cash. We also accept most insurance plans and will be more than happy to file and submit claims on your behalf. If you are unsure if we accept your insurance, please call us at (856) 956-3625.

We also offer low- and no- interest financing options through CareCredit. We will be happy to discuss our convenient financing with you or please visit www.carecredit.com for more information.

Patients are responsible for their estimated portion of the treatment. All fees will be clearly explained to you before the start of any procedure. Payment is due at the time services are rendered. A fee reduction is also given when a cash payment is made in full prior to treatment. Our aim is to provide the best dentistry services possible as discussed and agreed upon between you and your doctor.

SENIOR CITIZEN DISCOUNT

We are happy to offer senior citizen discounts!

If your insurance carrier has not paid within 60 days from the date of billing, you will be responsible for the outstanding balance. Any services provided which are not covered under your insurance plan must be paid in full at the time of your visit or upon notice of insurance claim denial.

A 2% service charge may be added to any outstanding balance over 60 days old unless previous arrangements have been made. Any account not paid according to our request will be turned over to a collection agency and a 30% fee will be added to the balance. This amount must be paid in full before any further appointments can be made.

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Emergency Walk-Ins Welcome

Serving our neighbors in communities surrounding Glassboro, Clayton, Pitman, Washington Township, Elk, Sewell, Franklinville, Mullica Hill, Elmer and Williamstown New Jersey.