Call Now To Set An Appointment

662.323.2876

405 Academy Rd. Starkville, MS 39759

DENTAL INSURANCE

We accept most dental insurance plans offered by major insurers, and as a courtesy to our patients, we are happy to file your claim electronically. In order to file your claim, we will need a copy of your dental insurance card, the subscriber’s ID # or Social Security #, and the subscriber’s date of birth. We always suggest that you call your insurer to verify dental coverage eligibility and benefits before your appointment.

Please be prepared to make any deductible payment or co-payment at the time of your appointment. We will be happy to answer any insurance questions you may have.

PAYMENT OPTIONS

We are happy to accept cash, personal checks, Visa, Mastercard, Discover, and Care Credit. Payment plans are available on selected dental treatment plans and procedures. This financing is handled on a case-by-case basis and must be agreed upon in writing before treatment is started.

Our office is proud to provide Care Credit® as a financing option to our patients. Care Credit is a personal line of credit for healthcare treatments and procedures for your entire family. To learn more or apply online, visithttp://www.carecredit.com.

NEW PATIENT FORM

Please fill out the form electronically below or print and fill out the PDF form manually and bring it in on your first visit. Regardless of which method you choose, please fill out all of the fields/pages. Thank you.

New Patient

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Bad BreathBleeding GumsClicking or Popping JawFood Collection b/t teethHistory of Fever BlistersGrinding or Clenching TeethLoose Teeth or Broken FillingsPeriodontal TreatmentSensitivity to HotSensitivity to ColdSensitivity when BitingSensitivity to SweetsSores or Growths in Mouth

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DO YOU HAVE OR HAVE EVER HAD:


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I authorize my insurance company to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of my signature on all insurance submissions. I understand that I am financially responsible for all charges whether or not paid by insurance, as well as, any finance charges, collection, attorney, and court fees used to collect on my account. By signing below, I also acknowledge that I have received copies of the office policies regarding dental insurance and cancelled/broken appointments. The above information is accurate and complete to the best of my knowledge. I will not hold Dr. Ferguson or any member of his staff responsible for errors or omissions that I may have made in the completion of this form.



Call Now To Make An Appointment.

CALL 662.323.2876