Creedmoor Pittsboro Smithfield Roxboro Leland NC Family Dentistry


 
About Dr Koren
Meet the Doctors
Meet the Management
Billing Department
Locations
Smithfield
Roxboro
Leland
Transportation Services
Patient Information
Appointments
Insurance
Financial Policies
First Visit
FAQ
Forms
Services
After Care Instructions
Office Policies
Patient Feedback
Career Opportunities


Patient Forms

forms


Patient Information and Medical History
  You can choose to be ahead of the game by printing and completing the medical history and patient information forms prior to your appointment. You can download them or quest for them to be mailed or sent by fax when scheduling your appointment.


Financial Policy
  You can print a copy of our financial policy for your records


HiPAA
   Review our Health Insurance Portability and Accountability Act and complete    the online release form.
        View the HIPAA form
        View the HIPAA Release form

Credit Card Authorization Form
  You can authorize the use of your credit card for payment of services even
  when you are notpresent with another family member.


Parental Consent Form
  You can authorize treatment to be rendered to your child in your absence.


Care Credit Application
  Apply for Care Credit to help offset the immediate expense of dental treatment.


Citi Health Card Application
  Apply for a Citi Health Card account for flexible financing of dental treatment.


Discount Plan Purchase Forms
  View instructions on how to purchase discount plans our offices currently
  accept.


Release for Dental Work during Pregnancy
  We require a release form the OBGYN of all pregnant women prior to
  providing dental care.

 
 


 
Smithfield Family Dentistry, 910 S. Bright Leaf Blvd, Smithfield, NC
Roxboro Family Dentistry, 347 S Madison Blvd, Roxboro, NC
Leland Family Dentistry, 117-H Village Rd, Leland, NC
 
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