Contemporary Family Dentistry

4347 W Northwest Hwy

Suite 128,

Dallas, TX 75220

(214) 366-4646 

 

 

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Patient Forms

Please bring the following forms, completed and signed, to your first visit, along with your insurance and/or form of payment information. If you are unable to do so, please arrive approximately 15 minutes early to complete this necessary paperwork prior to your appointment.

 

*Patient Information Form, English (in PDF form)

*Patient Information Form, En Espanol (in PDF form)

*Acknowledgement of Privacy Practices (in PDF form)

 

Payment Options

Our fees are based on the services rendered. For your convenience, we accept a wide range of payment options including indemnity insurance, PPOs, Care Credit and CitiHealth dental credit cards, as well as Visa, MasterCard, American Express and Discover.

As a courtesy, we will gladly contact your insurance provider on your behalf to inquire about your coverage and co-payment, which is due at the time of your visit. We will then process the balance as a claim to your insurance company. Please note that if your insurance provider is unwilling to pay the entire balance, the remainder will be your responsibility.