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  • Confidential Patient Information

    To help us meet all your dental healthcare needs we will need the following information. All information will be strictly confidential.
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  • Work Information

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  • Dental Benefits Information/Policy Holder

  • If you have dental benefits, and wish us to accept assignment on most services, the section below needs to be filled out accurately. Please note that you are responsible for any balances NOT covered by your insurance:

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  • In case of Emergency

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  • Current Medical Condition

    To serve you properly we will need the following information. All information will be strictly confidential.
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  • Medical History

    You will be asked few questions about your Medical History

  • Dental Condition

  • I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider who may release such information to you. I will notify the dentist of any change in my health or medication.

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  • Financial Policy

  • Our goal is to provide our patients with the highest level of dental care and transparency. We want to ensure that you understand exactly what is being done, the costs associated, benefits, and the risks. Once you agree to treatment, and book an appointment, you will be asked to pay the fee for the treatment rendered at the time of service.
    We can help you with sending an estimate prior to your appointment. However, with many benefit providers these days, we do not receive the breakdown of coverage, as the responses go directly to you. We cannot be held accountable for what your benefits cover and do not cover.


    For ongoing treatment, we will submit the estimates and claims on your behalf and help you with any requests your provider has. Please note there are hundreds of benefit plans, and they are a reflection of what your employer has chosen to sign you up for. If you contact your HR department, then can provide you with an actual booklet or link that you can bring to your appointment, which assists us in understanding your coverage.

  • You will be asked to pay the fee at the time of service. You are responsible for the payment of all the fees for dental care rendered at Willow West Dental. For your convenience if you would like we can contact your dental benefit provider so that you know what is covered. Since there is a possibility that the information given over the phone can be inaccurate, we cannot be accountable for what your benefits cover. We will submit the claim on your behalf and help you with any request your benefit provider might have.

  • APPOINTMENT POLICY

    A scheduled appointment means the dentist and their team have reserved a time specifically for you, and no other patients are seen at that time. If for some reason you know you cannot make your appointment, we require a 48 business hour notice (this does not include weekends) so we can give your scheduled time to other patients. Patients who do not follow this policy may be charged a $50/- fee and/or may no longer remain patients of this practice.

  • Privacy of your personal health information is an important part of our office, providing you with quality dental care. We understand the importance of protecting your personal health information. We are committed to collecting, using and disclosing your personal health information. We also try to be as open and transparent as possible about the way we handle your personal health information. It is important to us to provide this service to our patients. All staff members who come in contact with your personal health information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information. Please visit our full privacy policy statement available in our website https://willowwestdental.com/privacy-policy

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