We have made our new patient forms available to you as Adobe Acrobat files. For your convenience, we recommend printing and completing these forms at home.

Please remember to bring your completed forms with you for your first appointment. If you have any problem getting these files to print properly, please call our Chandler dental office and we will gladly send or fax them to you.

Please Print All 3 Forms

New Patient Form
HIPAA Form
Financial Form

FINANCIAL INFORMATION

Quality Care at Affordable Prices
You deserve a beautiful, healthy smile, and we don't want cost to stand in the way. At Fountains Family Dental, we provide advanced dental care at fees that won't break your budget. To help you pay for your dental work, we accept a variety of payment methods and dental insurance plans and offer third-party and in-house financing. We're sure to have a plan that's right for you!

PAYMENT METHODS ACCEPTED
• Cash
• Checks
• American Express
• Discover
• MasterCard
• Visa
• CareCredit and Chase

INSURANCE INFORMATION
We electronically file all insurance claims. Our front-office team works closely with insurance companies to maximize patient benefits and ensure speedy processing.

Our dentists are preferred providers for:

•Delta Dental
•Blue Cross Blue Shield
•United Concordia
•Humana
•Cigna
•Aetna
•MetLife
•Others – call to ask about your specific plan
We accept all PPO insurance plans.

FINANCING
We're pleased to offer third-party financing through CareCredit and Chase Health Advance. These leaders in patient financing offer no- and low-interest options for qualified applicants, as well as payment plans to suit almost every budget. Check out the CareCredit and Chase Health Advance websites for details and to complete an application online.

HEALTHY SMILES DISCOUNT PLAN
We're committed to your oral health. That's why we offer the Healthy Smiles Discount Plan. This in-house financing program gives health-conscious patients and families who don't have dental insurance access to quality dental care. The convenient Healthy Smiles Discount Plan offers an affordable membership fee and low co-pays for checkups and cleanings. Stopping dental problems before they start promotes strong, healthy, and beautiful smiles and prevents costly therapies in the future. Call for more information.