Patient Forms

If you would prefer, you can print out, complete and sign our patient forms to speed up checking-in for your first visit so we can get you in to see Dr. Buchwald as soon as possible. If available, please remember to bring in your insurance card when you come in, so we may make a copy of it for our records. We accept Medicaid for children. Most dental insurance is accepted. We accept Aetna, Assurant, Blue Cross Blue Shield (BCBS), Careington, Cigna, Delta, Dental Wellness, Dental Network of America, Dentamax, Guardian, Humana, Metlife and United Healthcare.

Please take a minute to print and fill out the patient information forms before your first appointment:

• HIPAA Notice of Privacy Practices  
  Please fill this out and turn it in at the front desk when you arrive for your appointment.
• New Patient Information  
  Information for our new patients about our fees, insurance and billing.
• Financial Policy Form  
  To keep our fees as low as possible, payment is expected on the date services are initiated. In some instances, we may ask that you prepay for your dental services to reserve special appointment times... This form needs your signature.
• Credit Card Pre-Authorization Form  
  This optional pre-authorization policy was created in response to many of our patient's desire to not be billed for small balances on their accounts remaining after all insurance payments have been made. As a convenience to you, this form provides us with the authorization to charge your credit card for outstanding balances up to $99.00 if this occurs
• No Show Policy & Fees  
  When our office books your appointment, we are setting aside a dedicated chair and time slot just for you. We only ask that if you must reschedule your appointment, that you please provide us with at least 24 hours’ notice to avoid the fee.
• Adult's Health History Update  
  Please fill this out and turn it in at the front desk when you arrive for your appointment.
• Child's Health History Update  
  Please fill this out and turn it in at the front desk when you arrive for your appointment.

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