• 2022 New Patient/Dental/Medical Form

  • Appointments:
    We reserve time and dental personnel for every patient's appointment. Please consider your appointment with us as confirmed when made. We certainly will provide the courtesy of reminders to you as an added benefit of being our patient.

    Should you need to reschedule an appointment please give us a 24-48 hour notice so that we can utilize the time for another patient or continuing education. There is a fee for last minute cancellations or rescheduling.

  • Financial Protocol:
    All Dental Treatment Fees are Due at Time service is rendered. If additional help is required, we can offer up to 3 payments with a Credit Card on file for Auto Payments up to 89 days.

    We Offer Care Credit or Lending Club for Extended Payments up to 6 Months.

    We are happy to process Dental Benefit claims on your behalf to maximize any dental benefits you have. Many Dental practices do not file dental claims for patients anymore.

    Rest assured that we will file and wait for the benefit payments assigned to us. However, we request you to please not consider us as your Insurance agents and we expect you to pay your estimated share of treatment fees at the time of service. If any Claim goes Unpaid beyond 60 Days it will become the Responsibility of the Patient.

  • Notice of Privacy:
    We are legally required to maintain the privacy of your health information. You have a right to look at the copies of your health information.

  • Assignment and release for insurance billing:
    I certify that I, and or my dependent(s), have dental benefit coverage and assign directly to Dr. Joseph Moore all of the insurance benefits, if any, otherwise payable to me for services rendered. I understand I am responsible for all charges paid by insurance or not. I authorize the use of my signature on all insurance submissions. The above named dentist may use my health care information and may disclose such information to the insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for services.

  • Parental Consent and Responsible Party Statement:
    Parental Consent is required for any unaccompanied minor child under the age of 18. We will treat unaccompanied Minor children as long as Parent/Guardian is available by Phone and the Parent/Guardian has signed Permission To Treat Consent Form and Medical History prior to Appointment.

  • I give permission to Moore Dentistry to perform all dental treatment
    on my child, 

  • regardless of my presence in the office. I understand and agree to Moore Dentistry's Treatment of Minor Consent Form. I agree to pay for all Services Provided to my child.

  • Dental History

  • Please answer Yes or No to the following:

    Personal History

  • Gum and Bone

  • Tooth Structure

  • Bite and Jaw Joint

  • Smile Characteristics

  • Medical History

  • DO YOU HAVE or HAVE YOU EVER HAD:

  • ARE YOU:

  • List all medications, supplements, vitamins and/or probiotics taken within the last two years

  • Should be Empty: