Patient Information Form

Patient Information

"*" indicates required fields

Welcome to RiverRock Dental!

We will strive to provide you with the best possible dental care. To help us meet all of your dental needs, please fill out these forms completely. If you have any questions or need assistance, please ask as we will be happy to help.

Date Of Birth **
Are you ?
Can we send you text message appointment reminders?

Subscriber/Responsible Person

Subscriber Name
Subscriber Address
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Failure to notify the office of an appointment cancellation less than 48 hours prior to your appointment can result in a broken appointment charge.

Method of Payment

Full payment for dental treatment provided is expected at the time of service. For your convenience, we accept cash, and all major credit cards. We are happy to file insurance for you. I authorize my insurance payment to go directly to River Rock DDS. It is your responsibility to provide our office with the necessary information concerning your insurance. Understand that your insurance plan is a contract between you and your employer and the insurance carrier. Treatment plans are an estimate only. Any and all non-covered services will be billed directly to you. All financial arrangements must be made in advance. Past due accounts will result in 15% finance charge. If my account is turned over to collections for legal judgement or action, I am responsible for all attorney fees, court costs and associated cost with collections.

I understand that I am ultimately responsible for all costs of dental treatment. I grant the right to the dentist to release my dental history and other information about my dental treatment to third party payers.

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