Forms

Please complete the document(s) below on the day of the appointment.
Upon Arrival for your appointment, please text or call (816) 591-2512.
You can text the patients First Initial and Last Name

NEW PATIENTS

New Patient Form
(Filled out once you’ve made an appointment. You can fill out the contact us form or call us at 816-781-5437 to make an appointment.)

Medical History Screening
(Filled out on day of appointment)

EXISTING PATIENTS

Medical History Screening
(Filled out on day of appointment)

Payment & Office Policies

Cost:

Cost of treatment will depend on the severity of the patient’s treatment needs. You will be able to discuss fees and payment options before treatment begins. We work hard to make pediatric dental care in Kansas City affordable and make sure that you realize your insurance benefits.

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Insurance:

We accept assignment from most insurance companies. As a courtesy to you, our office will file the necessary paperwork with our in-network insurance companies. It is your responsibility to provide our office with the necessary information relative to your insurance plan.

Services not covered by your insurance company must be paid for at the time of service. Professional pediatric dental care is provided to the patient, and not to an insurance company. Thus, the insurance company is responsible to you and you are responsible to Shoal Creek Pediatric Dentistry. We will help in every way we can in filing your claim and handling insurance questions from our office on your behalf, but you are ultimately responsible for payment of services rendered to your child.

Payment Methods and Options:

To assist you with your payment our office accepts cash, personal checks, cashier’s checks, money orders, Visa, Mastercard, Discover, American Express, and CareCredit. A $30.00 overdraft will be charged to your account for each returned or insufficient checks. CareCredit is a convenient, no interest low minimum monthly payment plan for your entire family designed to pay for healthcare charges not covered by insurance. You can reach CareCredit at (866) 893-7864 or visit www.carecredit.com for more information.

Contact Us

Want us to call you? We will contact you Monday-Wednesday during office hours.
Do not use this for emergencies. Please call us at 816-781-5437.
If after hours and you are a current patient you can call 816-781-5437 and press 5.