Patient Forms

THANK YOU for contacting the dental office of Dr. Cheryl Sobieraj and Dr. Gregory Saam. We are very happy that you have chosen us to take care of your dental needs.  In return, we will do our best to make your visits as pleasant as possible, and ensure that you receive the highest quality dental care available.

 

In order for our office to operate efficiently and effectively, we ask for your cooperation with the following policies: 

  • All payments are due at the time treatment is rendered.  If you have dental insurance however, our best estimate of your co-payment is due at the time treatment is rendered.  We will then submit the insurance form and accept direct payment from the insurance company for the balance. 
  • If there is need to cancel an appointment, notification must be given during normal office hours, at least 24 hours prior to that scheduled appointment.  Any cancellations made within 24 hours of the scheduled appointment will be considered a broken appointment.  The office will be forced to end the relationship after 3 broken appointments in any one year time span. 
  • We require a full series of radiographs to enable us to properly diagnose your oral health.  If these x-rays were taken at another office, you will need to print out the link entitled, "Transfer of Records".  You must sign this form and send to your prior dentist.

 

We will need a medical/dental questionnaire filled out as well so we can learn more about you.  Please print and complete the correct form and bring it with you to your dental visit. 

If you have ever been diagnosed with a heart murmur, rheumatic fever, mitral valve prolapse, congenital heart defect, or have a prosthetic joint, or history of heart surgery, please call our office as your physician may need to be consulted before dental treatment.

 

Again, thank you for choosing our dental office.  We hope to make this a life long relationship, and are looking forward to meeting with you!  If you have any questions, please do not hesitate to call our office.

                                                   

 

 

Our forms:

  • Patient Form (Child) PDF
  • Patient Form (Adult) PDF
  • X-Ray Transfer Form PDF

 

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