New Patient Registration
New Patient Information
Please call the front office to inquire about upcoming New Patient Registration dates
What to Bring
You will need to bring the following documents with you for the medical registration process. You must bring this information with you even if you have previously provided it for our dental clinic. Please Note: If you do not provide ALL of the information required, you will be asked to return will all of your documents at the next registration, as our staff cannot process incomplete applications.
- Current valid government issued photo identification (I.E. drivers license or passport)
- Payment of fifty dollars ($50.00). We accept cash, debit and credit card. (Fees may vary according to insurance carriers) Your deposit will be applied toward the total charges for the services rendered on your new patient appointment date. The actual total charges will vary depending on the discount for which you qualify and the services you receive at your initial consultation with the medical provider. We offer services on a sliding fee scale regardless of ability to pay.
- Medical, Dental, Pharmaceutical Insurance Card(s), only if applicable.
- Proof of income for the household in which you reside.
We accept the following items as proof of income:
REQUIRED for ALL
- Most current year's complete federal tax return (All forms and schedules filed).
from the following list bring all that apply to your household:
- Three (3) current and consecutive check stubs for ALL persons employed in the household.
- If paid in cash or with a stub-less check please provide a letter written and notarized by the employer. This letter MUST include employer's name, address, telephone number and signature, employees name, gross pay rate and pay period of an average pay cycle. We will NOT accept a self written letter.
- Recent statement from Social Security or recent bank statement showing direct deposit from Social Security
- Recent statement from Department of Labor or recent bank statement showing direct deposit from the Department of Labor for unemployment benefits.
- Recent statement from Department of Family and Children Services (DFCS) specifying the current benefits that are being provided. I.e. Food Stamps and Section 8 housing, Etc.
- Three (3) bank statements, court order, or notarized letter for any other income including child support, alimony, pension benefits, assistance from friends or family.