New Patient Forms & Info

New Patient Forms

For your convenience, all New Patient Forms are available here for download. All New Patient Forms are in PDF and can be downloaded and filled offline. If possible please fill them prior to your appointment to minimize wait time.

New Patient Forms (Registration)

  1. Please download the New Patient Forms in PDF format.
  2. You may print out the New Patient Forms and bring it to your first appointment OR email  the completed form to info@dearfielddentistry.com.

HIPAA and Informed Consent Forms

  1. Please review both documents.
  2. You may print out the form and bring it to your first appointment OR simply sign the forms at our office.

Dental Insurance

We currently accept all forms for insurance to aid you to maximize your benefits.  We are currently in network with Delta Dental, Metlife, Cigna, Guardian, Anthem, Aetna, United Healthcare and Dentemax Dental Insurances. 

Our goal is to minimize the out of pocket expense of our patients.  We are happy to process your insurance claims to maximize your benefits. Since insurance coverages can be confusing, we ask that you call or contact us with specific questions. Because insurance policies vary, we can only estimate your coverage in good faith but cannot guarantee coverage due to the complexities of insurance contracts. As a service to our patients, we will bill insurance companies for services. You are responsible for the copayment at the time of service and are fully responsible for whatever your insurance carrier does not pay. For patients who would like to know in advance what their benefits cover, we will be happy to submit your treatment plan for pre-estimates to your insurance carrier to minimize out of pocket surprises. If you have any questions, our staff is always available to answer them.

Payment Options

Dental treatment is an excellent investment to better your oral health and we understand the need  to be able to schedule treatment and care as soon as possible. We offer several financial options to help you achieve your treatment goals as soon as possible.

We gladly accept: Cash, Checks, American Express, Mastercard, Visa and Discover. As a benefit to our patients, we also work with most FSA/HSA spending accounts/cards.

Financing is available through CareCredit

Initial Exam – $99

Comprehensive Dental Exam, includes all digital xrays, photos, treatment planning and initial consultation. For our new Patients without Dental Insurance Coverage

Hygiene Special -$169

Regular dental cleaning, Fluoride application & checkup. Assess your dental health and have an opportunity to discuss your oral health, brushing habits and treatment options with your doctor or hygienist.

In Office Bleaching – $549

Zoom (Light Activated Bleaching) or Opalescence Boost (Non-Light Activated Bleaching). Get 2-8 Shades whiter teeth in under 1 hour. Discuss with your doctor which whitening option is best for your teeth.
Ask the staff about $50 Rebate for Zoom Whitening

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90 DEARFIELD DRIVE, GREENWICH CT 06831