ACCESSIBILITY

New Patient Info

Patient Forms - Franklin Street Dental

If you are a new patient to our office, the attached file contains our new patient bundle with forms that will need to be filled out when you arrive at our office.  Printing them, filling them out and bringing them with you will allow us to attend to your medical needs more quickly than completing them on your arrival.  Thank you and please call our office if you have any questions at all.

Patient Registration Form

Medical History

Privacy Acknowledgement

Privacy Notice

 

This web site uses files in Adobe Acrobat Portable Document Format  (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.


Payment Options

For your convenience, we accept cash, personal checks, money orders and major credit cards. Payment is expected at the time services are performed. When more extensive dental care is necessary, financial arrangements can be made with our office.

 
Insurance

We will assist patients with insurance research and any necessary pre-determination of benefits.
We will file pre-determination of forms whenever required.

Additionally, we will submit insurance electronically on behalf of the patient.

We do accept assignment of insurance and simply ask all patients to pay any co-pays and estimated patient payments at the time of service.





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Franklin Street Dentistry
2300 W Franklin St Evansville, IN 47712
Phone: (812) 424-6761 URL of Map