Forms & Info
Patient Forms
New Patients
Time: At our office, your new patient visit will take at least 90 minutes. You will receive the time you deserve to express your concerns, share your past experiences and to talk about what your goals and expectations are for your dental health and appearance. It is a time for you to ask questions so that you can make informed decisions about the dental care that is best for you.
Oral Cancer Screening Exam: Oral cancer is on a rapid rise, especially in the low risk population. Your dentist should feel and examine from both sides your: neck, floor of the mouth, and cheeks. You should stick out your tongue and the dentist should move it side to side to view all parts of it. Early detection means a much better prognosis and outcome.
Thorough Medical and Dental History Review: Current research is proving just how critically important dental health is to your overall health. It is extremely important that a thorough medical and dental history be obtained and reviewed to make an accurate and proper diagnosis. Your dentist should also ask about any problems or bad experiences you may have had. We know there is a human being with feelings and concerns attached to those teeth. We want to treat you, not just your teeth.
Complete Periodontal Charting: Periodontal gum and bone disease is the #1 undiagnosed illness in America and the #1 reason for tooth loss.
Complete Series of Diagnostic X-ray Images: Caring for and treating you without x-ray images a dentist cannot diagnose what he/she cannot see. That is why detailed images (within 5 years) showing ALL of the teeth, roots, and bone holding the teeth in place are a part of any complete and thorough examination. Images show cavities, bone loss around teeth, tumors, infections, failing restorations, and much more.
State of the Art Digital Scan: In addition to X-ray images, a digital scan is a fantastic diagnostic tool. Dr. Juracka can use your scan to order orthodontic clear aligners, teeth whitening trays, mouth guards and more in real time from this first scan. They also work to eliminate the need for traditional impressions in many cases giving the patient a more comfortable experience.
Payment Information
We accept the following methods of payment for your visits:
Cash
Check
Debit Card
Credit Card
We believe that healthy teeth and great smiles don’t have to hurt your budget. Financing to get those bigger things in life that we want and need is often the right choice. That is why we are proud to offer dental financing with CareCredit. Options available for short and long terms financing and even 0% financing to help you get the healthy and gorgeous smile you’ve always wanted. Click CareCredit to learn more and apply.
Insurance: Smiles for Life Dental Care follows a fee-for-service model. Payment is due at time of service. We are not a participating or preferred provider in any dental insurance plan. If you have dental insurance we will send in your claim electronically with in 24 hours of the rendered service. The amount you are reimbursed depends on the agreement your employer has negotiated with the dental carrier.
