Patient Information

Patient Forms

Please fill out the forms below before your first visit!

Patient Information

Insurance Information

Medical History

HIPAA and Financial Agreements

 

Post-Op Instructions

Below are links to post-op instructions that you may refer to. If you have any other questions, please feel free to give us a call!

• Post-Op Instructions for Oral Surgery

• Orthodontic Instructions

• Retainer Instructions

 

Insurance & Billing

We accept most private dental insurances, but please check if our office is in network with your own insurance.

 

Payment Options

 Cash/Check

• All Major Credit Cards

• CareCredit® (more information below)

 

Financing Options

CareCredit® is the credit card exclusively for healthcare services. With no up-front costs and no pre-payment penalties, CareCredit® lets you pay over time and frees up cash and credit cards for the other things you want or need. CareCredit® offers low monthly payment plans for healthcare procedures not commonly covered by insurance, including dental treatments. Plus, you can use your card again and again to pay for additional treatment for yourself or family members in any CareCredit® practice.

 

For more information or to apply online, visit CareCredit.com.

Appointment request
Need an appointment at Bencivengo & Ko? Requesting an appointment at family and cosmetic dental office is now easier than ever. Fill out the form below and we'll contact you to find a time that fits your schedule. Start your journey towards a beautiful smile with us today!
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