New Patient Forms

     

     Welcome to our practice! You’ll be pleased you’ve selected Dan Dube Dentistry as your Wilmington, NC general dentist.

 

 

     Our entire team takes pride in providing you and all new patients with gentle personalized care done the right way the first time. Dr. Dube takes the time to make a professional diagnosis and carefully explain it to you. 

 

     We have reserved a new patient appointment for you which will last approximately 90 minutes. During this visit, we will work with you to develop a treatment plan that specifically meets your dental goals.

 

     Our Hygienists and Dental Assistants are trained to work with you to help provide a comfortable and understanding environment to begin the treatment process. They will show you home care techniques that, if utilized correctly, will help your teeth remain healthy. Our Financial Coordinator will discuss your treatment needs and go over insurance benefits & payment options available to you.

 

     Please fill out the following forms prior to coming to our office and bring with you to your first appointment.

 

• New Patient Package

• Medical History Form

 

     HIPAA stands for Health Insurance Portability and Accountability Act.  It is a set of standards created by the U.S. Congress to streamline the flow of information in the healthcare system and protect your personal health information.  As part of our compliance with HIPAA, we provide you with a notice of Privacy Practices and ask you to sign a form acknowledging your receipt of the Notice.

 

Records Release Form

 

• Release Forms

 

Dental Insurance

 

     We accept most dental insurances and are happy to submit the claims necessary to help you receive the full benefits of your coverage.

 

     It is customary that payments, co-payments, and insurance deductibles are due as services are rendered. We accept cash, check, Visa, MasterCard, Discover, Care Credit, American Express, and HAS/FSA.  When a significant procedure or treatment plan has been proposed, convenient financing through a health care credit plan may be of financial assistance. Extended payment plans of 24-60 months are also offered, however these plans include finance charges at the patients responsibility.

 

     The following institution can guide you through this process:

 

• Springleaf – Personalized financing tailored to your needs. Apply in our office. (Financing only available to residents in the state of North Carolina)

 

• Care Credit-  If you elect to use Care Credit with a 6 or 12 month payment plan, Dr. Dan Dube will cover the interest charges.  Extended payment plan interest is patient responsibility.

 

Cancellation Policy

 

     Thank you for giving us the opportunity to put our years of training and experience to work for you!! We truly look forward to meeting you and helping you achieve your oral healthcare needs.

 

     Kindly notify us at least two (2) days in advance, should any unforeseen or emergency circumstances prevent you from making your scheduled appointment.