Home
Patient Account Information
Please fill out all these forms before your first visit:
☐ Medical History Form
☐ Patient Account Information
☐ Appointment Preference Form
☐ Corah's Dental Anxiety Scale
☐ Mount Sinai Dental Fear Inventory



First Name
Last Name
Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
Name of Spouse/Partner
Closest Relative
Phone
Employer
Occupation
Business Address (include floor number)
City
State
Zip
Person Financially Responsible for Account
Phone (if different from self)
Address (if different from self)
City
State
Zip



In an effort to provide you with quality Dental Care and maintain our present fees by minimizing billing procedures, payment is requested at the time of your visit for all charges $250 or less. Please check one.
Payment by cash
Payment by check
Payment by credit card

Dental treatment is an excellent investment in an individual's medical and psychological well being. Financial considerations should not be an obstacle to obtaining this important health service. Being sensitive to the fact that people have different needs in fulfilling their financial obligations, we are providing the following payment options.

If you have dental insurance, a completed dental claim form must be on file with this office. It is also your responsibility to notify us of any changes. For involved treatment greater than ($250), we will accept your insurance assignment towards your bill as long as a definitive arrangement (see options below) is made for your estimated patient responsibility.

Your insurance is a method for you to receive reimbursement for fees you have paid to the doctor for services rendered. Having insurance is not a substitute for payment. Many companies have fixed allowances or percentages or other limitations based on your contract with them. It is your responsibility to pay the deductible, co-insurance, and any other balances not paid for by your insurance. We will assist you in receiving reimbursement as much as possible, but you are responsible for your bill.

Prepayment Courtesy
5% No-Billing Courtesy for treatment plans of $2,000 or more. Must be paid 48 hours prior to appointment.

3 Month Interest-Free Option (Separate form required).
1/3 of Total Fee is billed either by an: 1) Automatic monthly billing to your Visa, Mastercard, Discover or American Express or 2) Automatic monthly debit from your checking account

CareCredit Plan
No Initial Payment. Payment plans up to 60 months with monthly payments as low as $22/month (for a $1000 balance) Ask in office for full illustration. Must be approved


I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.

Click to certify.

If you have any problems or questions regarding these forms, please call our office at 212.838.2900. We will be glad to assist you.







This site and contents ©2008 Michael Krochak, DMD All Rights Reserved
Our Philosophy of Care
Our People
Dental Technology
Services and Amenities
Appointments
Emergencies
Fees and Insurance Processing

Conquering Dental Fear