Online Forms

New Patient Forms

If your child is a new patient to our pediatric dental office, the attached file contains our new patient bundle with forms that will need to be filled out when you arrive at our office. Printing them, filling them out, and bringing them with you will allow us to attend to your medical needs more quickly than completing them on your arrival. Our team is Trilingual (English, Spanish and Gujarati). Thank you and please call our Naperville children's dentists, Dr. Eryn, and Dr. Rosa if you have any questions at all.

Proof of School Dental Examination Form

Dental Record Release Form

Payment Options

For your convenience, we accept cash, personal checks, Care Credit (link below), money orders and major credit cards. Payment is expected at the time services are performed. When more extensive dental care is necessary, financial arrangements can be made with our office.

Insurance

As a service to our patients, our practice accepts most dental insurance programs, including non-managed care, indemnity (traditional) and PPO out-of-network. We do not participate with Medicaid, Medicare or any other government funded plans. Our Business Team will prepare all the necessary forms for your dental benefits. However, we remind you that your specific policy is an agreement between you and your insurance company. Please keep in mind that you are responsible for your total obligation should your insurance benefits result in less coverage than anticipated. Our staff will gladly submit a pre-treatment estimate to your insurance company so that you will know what your benefits will be. The fees charged for services rendered to those who are insured are the usual and customary fees charged to all our patients for similar services. Your policy may base its allowances on a fixed fee schedule, which may or may not coincide with our usual fees. You should be aware that different insurance companies vary greatly in the types of coverage available. Also, some companies take care of claims promptly while others delay payment for several months.