New Patients

New Patient Forms

Please print the forms below, sign them, and bring them with you to your first visit. This will help expedite the check-in process, so we can begin your exam right away.

• Patient Information
• Dental and Medical History Form
• Notice of Privacy Practices
• Amalgam-Free Form
• HIPAA Form

Patient Amenities

At Elmbrook Family Dental, your comfort and satisfaction is our #1 goal. To make your visit as pleasant as possible, we offer the following amenities to our patients:

• Cable television in every room
• Comforting massage chairs (in some rooms)
• Neck pillows
• Baskin-Robbins milkshakes after some procedures
• Patient referral program - earn gift cards for eligible referrals!

Financial Information

At Elmbrook Family Dental, we want to make quality care affordable for everyone. For this reason, we have developed an extensive menu of financial options. We accept all traditional dental insurance plans and are Preferred Providers in most PPO's. We offer complimentary benefit analysis so that you may see an estimated breakdown of your benefits. No insurance company really pays 100% of the bill.

For payment we accept:

• Cash, Check, Debit Card, and ACH (auto withdrawal)
• All major Credit Cards, CareCredit, and CITI Healthcare.
• All fees and insurance co-pays are due at the time of service unless prior arrangements have been made.

Payment Options:

Full Payment at time of Service:

We offer an 8% courtesy discount for full payment at the time of service, and 10% if treatment is prepaid at time of scheduling. We also offer a 10% senior discount with payment at the time of service, and 12% if treatment is prepaid at time of scheduling. No additional discounts, discount plans, or insurance plans will be honored in combination with this allowance.

In Office Financing with Approved Credit

• Up to three months interest free with automatic debit from your checking, debit, or credit card.
• Up to 12 months interest free through Dental Banc with an initial down payment – auto withdrawal from your checking or savings account.
• We do not send statements. If a billing statement is required, we reserve the right to assess interest at 1% per month (12% annually).

External Financing with Approved Credit

• 3, 6, or 12 months interest-free financing through CareCredit or CITI Healthcare.
• Up to 60-month financing is also available to provide lower monthly payments.