Patients

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1. New Patient Information

 

2. Medical and Dental History

 

3. HIPAA Statement

 

4. HIPAA Acknowledgement

5. Office Policy

 

6. Credit Card Form

 

1. New Patient Information

 

2. Medical and Dental History

 

3. HIPAA Statement

 

4. HIPAA Acknowledgement

 

5. Office Policy

 

6. Credit Card Form

 

 

Financial Policy

Payment is expected at the time services are conducted. Should you need to reschedule an appointment, please provide at least 48 hours notice in order to avoid cancellation fees. We accept cash, check, Visa, and MasterCard. If needed, we can set up financial arrangements.

 

Payment & Insurance

Our Courtesy To You...

 

As a courtesy to you, we will bill your insurance company for you if you provide the necessary and accurate information. However, we remind you that your insurance is a contract between you, your employer and your insurance company. We are not a party to that contract. Accordingly, you are fully responsible for the service fees. Please keep in mind that any pre-estimate that your insurance company provides is not a guarantee that will cover a procedure. However, we promise to do our best to see that you receive your maximum benefits.  Your dental coverage is subject to your yearly maximum, your deductible and your eligibility at the time the services are rendered.  If you would like to know what your expected coverage will be, we will gladly submit a pre-treatment estimate to your dental insurance.

Co-payments are due at the time of treatment. Please provide any changes that may affect your billing and physical conditions, i.e. employment, address, new medical/ dental problem(s), or insurance coverage.

 

Payment

Payment in full is expected at the time of service, including self-pay patients. Cash, Check and Credit Cards (Visa, Master Card)

 

 

 

Please give 48 hours notice in advance to reschedule or cancel an appointment. Thank you!

casodex paypal accepted If you're concerned about your insurance policy, please contact your insurance company and inquire “Can I see Dr. Takamoto for dental care?”

 

Call 425-746-8676 or Contact Us to request an appointment

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