Buchwald Dental logo
Monday - Thursday 7AM - 4PM, Friday 8AM - 3PM
Phone: (972) 644-3280

Patient Forms

If you would prefer, you can print out, complete and sign our patient forms to speed up checking-in for your first visit so we can get you in to see Dr. Buchwald as soon as possible. If available, please remember to bring in your insurance card when you come in, so we may make a copy of it for our records. We accept Medicaid for children. Most dental insurance is accepted. We accept Aetna, Assurant, Blue Cross Blue Shield (BCBS), Careington, Cigna, Delta, Dental Wellness, Dental Network of America, Dentamax, Guardian, Humana, Metlife and United Healthcare.

  Description Last Updated  Download 
NEW PATIENT FORMS
HIPAA Notice
of Privacy
Practices
Please fill this out and turn it in at the front desk when you arrive for your appointment. 6/2/2020 Here
New Patient Information Information for our new patients about our fees, insurance and billing. 6/2/2020 Here
Financial Policy
Form
To keep our fees as low as possible, payment is expected on the date services are initiated. In some instances, we may ask that you prepay for your dental services to reserve special appointment times... This form needs your signature. 6/2/2020 Here
Credit Card
 Pre-Authorization 
Form
This optional pre-authorization policy was created in response to many of our patient's desire to not be billed for small balances on their accounts remaining after all insurance payments have been made. As a convenience to you, this form provides us with the authorization to charge your credit card for outstanding balances up to $99.00 if this occurs. 6/2/2020 Here
No Show
Policy & Fees
When our office books your appointment, we are setting aside a dedicated chair and time slot just for you. We only ask that if you must reschedule your appointment, that you please provide us with at least 24 hours’ notice to avoid the fee. 6/2/2020 Here
Children's
Health History
Update
Please fill this out and turn it in at the front desk for your child when you arrive for your appointment. 6/2/2020 Here
Adult's
Health History
Update
Please fill this out and turn it in at the front desk when you arrive for your appointment. 6/2/2020 Here