Patient Forms

Forms, Insurance, and Financial Information for Pediatric Dental Care in Winston-Salem

We ask that you use our secure access portal to complete all forms prior to coming to our office for your child’s appointment. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it. For assistance, please call us at Winston-Salem Office Phone Number 336-659-9500.

Call us to get started at Winston-Salem Office Phone Number 336-659-9500 or use our online form.

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Patient Policies and Information

Broken Appointment Policy | Financial Policy | Insurance Information | Billing

Notice of Privacy Practices (PDF file)

Broken Appointment Policy

The scheduled appointment is reserved specifically for your child. Any change in this appointment affects many patients.

If a cancellation is unavoidable, please call our office at least 24 hours in advance so that we may offer that appointment time to another child. Your account may be assessed a $50.00 broken appointment fee if 24-hour notice is not given when needing to change an appointment.

We try to appoint younger children early in the day because they are at their best at this time. Whenever possible, older children can be appointed outside regular school hours.

Ready To Schedule Your Child’s Dental Appointment?

Call us: 336-659-9500

Financial Policy

Payment is requested at each appointment as service is rendered and can be made by cash, check, American Express, Discover, Visa, MasterCard or CareCredit.

You may apply online for CareCredit. Please note that in order to use this financing option for treatment payment you must be approved for CareCredit before your child’s appointment.

Please be aware that the parent bringing the child to our office is legally responsible for payments on all charges. We cannot send statements to other addresses.

Insurance Information

We are not considered “in-network” with any dental insurance companies. For our patients with dental insurance, you will be asked to provide accurate and complete insurance information, as we are happy to file your insurance benefits for you.

Any estimated copay is payable at the time of treatment. If we do not receive payment from your insurance company within 30 days, you will be expected to pay for all dental services completed.

Call us at Winston-Salem Office Phone Number 336-659-9500 if you have any questions.

Patient Links of Interest


As a courtesy, we will file your primary dental insurance claim for you provided that we have received all of your insurance information on the day of the appointment.

We will also accept the assignment of benefits & file your claim on your behalf.  We ask that you be familiar with your insurance benefits as it is a contract between you and them.

Please be aware our office does not file secondary insurance.

We file all insurance electronically, so your insurance company will receive each claim within days of treatment. Please note that some insurance carriers will not reimburse our office directly.

In such instances, you will be responsible for payment in full at the time treatment is completed & your insurance company will send you the reimbursement check directly. Call us if you have questions: Winston-Salem Office Phone Number 336-659-9500.

Please understand that there is no direct relationship between your dental insurance company and our office.  Your insurance company is responsible for how they process claims and what benefits are payable on a claim.

We can only assist you in estimating your portion.  We will verify your benefits prior to treatment whenever possible.  If you have any questions we will be happy to assist you. Please do not hesitate to call: Winston-Salem Office Phone Number 336-659-9500.

Interesting Insurance Facts:

Dental insurance is meant to be an aid in receiving dental care.  Many patients believe that their insurance pays 90%-100% of all dental fees.  This is simply not true!

Actually, most insurance plans pay between 50%-80% of the average total fee.  Some pay more; some pay less.  The percentage paid is usually determined by how much you or your employer has paid for coverage, or the type of contract your employer has set up with the insurance company.

You may have noticed that sometimes your dental insurer reimburses you or the dentist at a lower rate than the dentist’s actual fee.  Frequently, insurance companies state that the reimbursement was reduced because your dentist’s fee has exceeded the usual, customary, or reasonable fee (“UCR”) used by the company.

A statement such as this gives the impression that any fee greater than the amount paid by the insurance company is unreasonable, or well above what most dentists in the area charge for a certain service.

This can be very misleading and is not accurate.
Insurance companies set their own schedules and each company uses a different set of fees they consider “allowable”.

These allowable fees may vary widely because each company collects fee information independently.  Frequently this data can be three to five years old leading to a larger profit margin for the insurance companies and a larger copay for you.

Unfortunately, this gives the misconception that your dentist is “overcharging” for their services.  In general, the less expensive insurance policy will use lower UCR figures.

Deductibles and coverage percentages must be considered when estimating dental benefits.  Consider the following illustration assuming the fee for service is $150.

Assuming the insurance company allows $150 as its UCR fee, we can determine the payable benefits by the policy.  First, a deductible, on average $50 and payable by you, is subtracted, leaving $100.

Then assume the plan will pay 80% for this particular charge.  The insurance company will then pay 80% of $100 or $80.  Out of a $150 fee they will pay an estimated $80 leaving a remaining portion of $70 to be paid by the patient.

Of course, if the UCR is less than $150 or if your plan pays at a lower percentage, then the insurance benefits will also be significantly less.

It is most important that you keep us informed of any insurance changes such as policy name, insurance company address, or change in employment so that we may continue to provide you with the most accurate estimate possible.

We appreciate your cooperation and understanding.

Please notify us if your dental coverage is embedded in your medical policy. Although we are unable to file to medical insurance companies we will gladly provide you with the necessary paperwork for you to submit your claim.

Note: All policies are subject to change without notice.