Longview: 903-757-0534 | Atlanta: 903-796-6250 | Gilmer: 903-757-0534 | White Oak: 430-625-3873
   

Financial

We never want costs to stand in the way of quality treatment, which is why we are dedicated to providing our patients with care that is both effective and affordable. Your treatment plan will include a breakdown of all applicable fees, and we will inform you of all costs before treatment is administered.We offer a variety of payment options to meet your needs. Our office accepts payments by cash, checks, and Visa, MasterCard, American Express and Discover credit cards. If full payment is made at the onset of treatment, we offer a fee discount. We also offer a discount to siblings receiving treatment.

Affordable Financing Options 
Don’t let finances stand in your way for achieving the beautiful, healthy smile you deserve! We are pleased to offer in-house financing to help make your treatment more affordable. This is a flexible payment option that allows  you to pay for your treatment over a period of time so you can focus on what matters most – keeping your smile healthy!

If you have any questions about financing or payment, ask us! We will thoroughly explain your choices and work hard to accommodate you.

Insurance

Our office is committed to helping you maximize your insurance benefits. Because insurance policies vary, we can only estimate your coverage in good faith but cannot guarantee coverage due to the complexities of insurance contracts.

When you first visit our office, bring your current insurance card with you. If you change insurance companies or join another employer’s plan, please be sure to let us know. If an insurance referral is necessary, please bring the completed form with you to your appointment.

Please note: Although we file all insurances, we do not accept Medicaid or CHIP insurance plans.

We will fully attempt to help you receive full insurance benefits; however, you are personally responsible for your account, and we encourage you to contact us if your policy has not paid within a reasonable timeframe. If we are not contracted under your insurance, you will be given a copy of services and charges to file with your insurance claim form.

Please fill out the form below.

Patient Information



*
Male
Female


Home
Cell

Parent/Guardian Information


Single
Married
Divorced
Widowed
Significant Other

Guardian 1


Home
Cell

Home
Cell
Guardian 2


Home
Cell

Home
Cell

Emergency Contact


Insurance Information



Dental History


Yes
No
Yes
No
Yes
No
Yes No
Teeth
Mouth
Chin
Yes
No
Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Thumb/Finger Sucking
Chewing/Eating Problems

Medical History


Yes
No
Yes
No
Yes
No
Yes
No
N/A
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
 Anemia
 Arthritis, Rheumatism
 Artificial Heart Valves
 Artificial Joints
 Asthma
 Back Problems
 Blood Disease
 Cancer
 Chemical Dependency
 Chemotherapy
 Circulatory Problems
 Cortisone Treatments
 Cough, Persistent
 Coughing Blood
 Diabetes
 Epilepsy
 Fainting
 Glaucoma
 Headaches
 Heart Murmur
 Heart Problems
 Hemophilia
 Hepatitis
 High Blood Pressure
 HIV/AIDS
 Jaw Pain
 Kidney Disease
 Liver Disease
 Mitral Valve Prolapse
 Pacemaker
 Radiation Treatment
 Respiratory Disease
 Rheumatic Fever
 Scarlet Fever
 Shortness of Breath
 Skin Rash
 Stroke
 Swelling of Feet or Ankles
 Thyroid Problems
 Tobacco Habit
 Tonsillitis
 Tuberculosis
 Ulcer
 Venereal Disease

Authorization


I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.