New Patients

PLEASE READ/PRINT THE WELCOME LETTER. IT WILL PROVIDE YOU WITH AN OVERVIEW OF THE PROGRAM AND WHAT WE’LL NEED FROM YOU TO BEGIN THE PROCESS OF BEING SEEN AS A NEW PATIENT FOR SENIOR smile.

Please be aware that we have recently changed our pricing for certain services. For more information, please see our notice document here.

Get Started – Complete the Intake Form

Intake Form

PLEASE SEND INTAKE FORM BACK TO THE OFFICE VIA:

SCAN and EMAIL TO: reception@srsmile.com

When the INTAKE FORM is received by the office, you will then receive a call for the remaining paperwork to be done. If you do not get a call in 3 days, please call the office to check if the intake form was received. Once all the paperwork is received and checked, you will receive a call with the day of the appointment. If you have any questions, please feel to call the office any time at 301-875-7477.

PAYMENT INFORMATION

WE ARE A FEE FOR SERVICE PRACTICE, WE ARE ABLE TO PROVIDE YOU WITH A PAID INVOICE FOR YOU TO SUBMIT TO YOUR INSURANCE FOR REIMBURSEMENT.

A CREDIT CARD WILL BE REQUESTED TO HOLD ON FILE AT THE INITIAL APPOINTMENT. THE CREDIT CARD ON FILE WILL BE CHARGED FOR THAT DAY’S SERVICES, UNLESS OTHERWISE NOTED. IF YOU WISH TO BE BILLED, PLEASE SHARE IN ADVANCE. THE BILL WILL REQUIRE PAYMENT WITHIN 30 DAYS. LATE FEES WILL START ACCUMULATING EVERY 30 DAYS, A CHARGE OF $25.00 WILL ACCRUE PER MONTH.

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