RESOURCES

Insurance and patient forms, in one place.

We accept all PPO Insurance with
out of network benefits.

For our uninsured patients we now offer the following
In House Dental Membership Plan.

Adults (14 and over)

$412.00 / year



2 Cleanings



Yearly check up x-rays (4 Bitewings)



Yearly check up exam



2 Fluoride treatments

Children (13 and under)

$398.00 / year



2 Cleanings



Yearly check up x-rays (2 Bitewings)



2 Check up exams



2 Fluoride treatments

4 Month Perio Patients

$660.00 / year



3 yearly cleanings (Perio Maintenance)



Yearly check up x-rays (4 Bitewings)



Yearly check up exams



2 Fluoride treatments

3 Month Perio Patients

$812.00 / year



4 yearly cleanings (Perio Maintenance)



Yearly check up x-rays (4 Bitewings)



Yearly check up exam



2 Fluoride treatments

All plans include 20% off of our regular fees for any additional services.

Terms and conditions apply. Please read disclosures carefully.

This is NOT an insurance plan

Membership Plan Terms and Conditions

Enrolling in our In-House Membership Plan gives you the opportunity to receive your dental treatment exclusively at our practice for reduced fees. It can not be combined with dental insurance, or other reduced fee dental plans.



The effective date of this plan is the day you sign the agreement and is good for 1 year from that date.



Exams, x-rays, cleanings and fluoride must be preformed within the year and can not be carried over to the next year.



The plan is non-transferable. Family members can not be substituted for another family member.



Plan is only valid for services, products are not included.



Payment for services not covered 100% by the membership is due in full at time of service.



Failure to keep check up appointments may result in termination of the membership.



The purchase amount of the membership plan may be made in payments, half is due at time of enrollment with the other half made in equal monthly payments over the first 6 months of the plan.



Failure to make payment on time for the membership plan may result in the termination of the membership.



This plan is non-refundable. No refunds will be given if patient chooses not to use their dental plan after the first 30 days following enrollment.



Members must remain active in the membership throughout the duration of Sure Smile Orthodontic treatment.



Rates are subject to change annually.

New patient forms

To help speed up your initial visit, please print and fill out the following paperwork prior to your appointment.

Insurance and patient forms, in one place.

We accept all PPO Insurance with out of network benefits.

Adults (14 and over)

2 Cleanings

Yearly check up x-rays (4 Bitewings)

Yearly check up exam

2 Fluoride treatments

Children (13 and under)

2 Cleanings

Yearly check up x-rays (2 Bitewings)

2 Check up exams

2 Fluoride treatments

4 Month Perio Patients

3 yearly cleanings (Perio Maintenance)

Yearly check up x-rays (4 Bitewings)

Yearly check up exams

2 Fluoride treatments

3 Month Perio Patients

4 yearly cleanings (Perio Maintenance)

Yearly check up x-rays (4 Bitewings)

Yearly check up exam

2 Fluoride treatments

Membership Plan Terms and Conditions

The effective date of this plan is the day you sign the agreement and is good for 1 year from that date.

Exams, x-rays, cleanings and fluoride must be preformed within the year and can not be carried over to the next year.

The plan is non-transferable. Family members can not be substituted for another family member.

Plan is only valid for services, products are not included.

Payment for services not covered 100% by the membership is due in full at time of service.

Failure to keep check up appointments may result in termination of the membership.

The purchase amount of the membership plan may be made in payments, half is due at time of enrollment with the other half made in equal monthly payments over the first 6 months of the plan.

Failure to make payment on time for the membership plan may result in the termination of the membership.

This plan is non-refundable. No refunds will be given if patient chooses not to use their dental plan after the first 30 days following enrollment.

Members must remain active in the membership throughout the duration of Sure Smile Orthodontic treatment.

Rates are subject to change annually.

New patient forms

Welcome to Hitchcock Dental

Patient Medical History

Child Medical History

General Dentistry Informed Consent

HIPPA Document

Acknowledgment of Privacy Practice

Notice of Privacy Practice

In-House Dental Membership Agreement

We accept all PPO Insurance with
out of network benefits.

Welcome to
Hitchcock Dental

Patient Medical
History

Child Medical
History

General Dentistry
Informed Consent

HIPPA
Document

Acknowledgment
of Privacy Practice

Notice of Privacy
Practice

In-House Dental
Membership Agreement