Pediatric Dentistry of Union

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NEW PATIENT INQUIRY and INSURANCE VERIFICATION FORM

WE DO NOT participate with Medicaid and NJ FamilyCare. Additionally, HMOs and DMOs
***Existing patients, please call the office directly to schedule your next or follow-up appointment***

Please note: This form is for new patients to request information regarding scheduling your first visit and understand you insurance benefits. Please complete and submit this form and our insurance coordinator will contact you as soon as possible with an explanation of your insurance benefits as well as to help you schedule your first visit. You will have to complete New Patient Intake forms separately before for your first visit.

Regarding your INSURANCE:
Please READ before filling out this form
We work with a wide range of dental insurance plans however, WE DO NOT participate with Medicaid and NJ FamilyCare. Additionally, HMOs and DMOs typically cover in-network providers only. If your plan is either an HMO or a DMO it will not cover our services.

In the event that we don't participate with your insurance plan, we can offer flexible payment options including a monthly payment plan.

Privacy Policy: https://www.pdofu.com/disclaimer/

Parent/Guardian Full Name *

Parent/Guardian Phone *

Home Address *

City, State, Zip *

Parent/Guardian e-mail *

Child's Full Name *

Child's D.O.B *

YYYY

Second Child's Full Name (If making appointment for second child)

Second Child's D.O.B

YYYY

Third Child's Full Name (If making appointment for third child)

Third Child's D.O.B

YYYY

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