Patient Info

Patient Information

Below are the forms that you will need for your first visit to our office. Please fill out and submit the forms online below. If you prefer filling out our paperwork in office using our Patient Kiosk, please plan to arrive to your appointment 10 minutes early.

Please be advised that by using our online forms to contact our office, we are not establishing a doctor-patient relationship. As a user of this mode of communication and of our website, you assume all risks with placing confidential information into this portal. This form of communication is not intended for acute, emergency, or life-threatening health conditions. If you believe you are having a dental emergency, contact 911 or go to your nearest emergency department.

Prior to scheduling your appointment, please be sure to read this thoroughly:

It is the policy of Prescott Dentistry to require 48 hours advance notice for all appointment cancellations. All appointments are considered confirmed at the time that they are booked. In consideration of our patients time we do not double book our providers, therefore patients that miss appointments are of great concern to the providers at Prescott Dentistry. A missed appointment is a missed opportunity for another patient to receive the care that they need. In light of this, when a new patient “misses” or “no-shows” their first appointment at our office, we will not be able to re-schedule that time with our providers.

Fragrance Free Space

Patients with Dental Insurance

For patients with dental insurance we are happy to work with your carrier to maximize your benefit and provide you with the documentation you need to receive reimbursement for your treatment.

Even if you have Dental Insurance, you are responsible for your account, not your insurance company. Most plans are designed to pay a portion of the total cost of services based entirely on the premiums paid for the coverage as it is with any other type of insurance. The percentage covered is based on what the insurance carrier “allows” for a particular procedure, not what the dentist may actually charge. If there are questions regarding your coverage or the payment the insurance company has made, it is your responsibility to contact them for clarification. We are not a party to contract between you, your employer, and the insurance company and cannot be held responsible for benefits you may or may not receive. As a courtesy to you, we will submit a claim to your insurance company within one working day, but that is the extent of our responsibility as long as the claims are accurate. Because we are not contracted with your insurance company, we as that you pay the entire fee at the time of service and we will have your insurance company reimburse you directly.

For NEW PATIENTS:  You must confirm your appointment within 48 hours of your appointment time or your appointment will be cancelled by our office so that we can see other patients with dental needs.

For ALL PATIENTS: All treatment/visits that are scheduled at our office must be confirmed by you prior to your visit and we will call as well as email you to do so.  For patients who have three (3) missed or canceled appointments without 48-hour notice we will charge a missed appointment fee of $100 to your account.  Meaning that if you miss your appointment or fail to give us 48-hour notice prior to a cancellation, we will place an invoice on your account for the $100 owed.  This charge will not be applied to future appointments or treatment, the $100 fee will cover the time that you had reserved with us for the missed visit.

¹Subject to credit approval

CareCredit