We are asking you to complete new patient questionnaire enabling our clinical and administrative staff to prepare for your first visit and to make your check-in for your appointment quicker and easier.
Our questionnaire consists of 5 documents. To complete a document, simply fill out the fields with the requested information. While most of the fields are optional, certain fields, marked by asterisks, must be completed. When you have completed a document please review your entry, click the Submit button to move to the next document. Please don’t use your browser’s Back or Forward buttons. Use of these buttons may ‘undo’/’redo’ your recent actions and may result in errors.
Please note that the information you will submit will be encrypted for your protection and goes directly to our office. We appreciate the time that you will spend providing the information helping us prepare for your visit.
NO INSURANCE? NO PROBLEM!
As an Exceptional Dental Savings Plan member, you can enjoy:
- No yearly maximums
- No waiting periods
- No deductibles
- No claim forms
- No pre-authorizations
- No pre-existing conditions limitations
- Includes orthodontics and cosmetic procedures
2 Family Members
*Parent/Child OR Spouse/Spouse
3 Family Members
Each Additional Family Member
- All family members must reside in the same household.
- Family members may not be substituted for one another.
- Children may be included up to age 18 or up to age 26 if full-time student enrolled in school.
- 1 New Patient/Comprehensive Exam
- 1 Annual/Periodic Exam
- 1 Emergency/Limited Exam
- 1 Full Set of X-rays or Panoramic every 3 years of membership
- Periapical X-rays as needed
- 4 Bitewing X-rays
- 2 Adult Cleanings (Prophylaxis or Periodontal Maintenance)
- 2 Child Cleanings
- 2 Fluoride Varnishes
- Sealants (up to age 14)
- Fillings and Core Build-ups
- Root Canals
- Deep Cleanings
- Night Guards
- ClearCorrect Clear Aligners
- 3D X-ray
• No refunds
• Membership fee is due at time of enrollment
• Membership is valid for 1 year
• Member portion is due at time services are rendered
Cannot be used:
• In conjunction with another dental plan or CareCredit
• In conjunction with coupons, discounts, or special offers
• For referral to specialists
• For any products
This membership plan is NOT an insurance plan and is only honored at Exceptional Dental.