Patient Forms

To save yourself some time on the first appointment, you can fill out our patient forms at home. Click on the buttons below for printable PDF forms. If you have any questions, please feel free to call our office:  307-362-3121

Forms:  (Click Below for Printable Forms)

New Patient InformationHealth History formGeneral Consent FormFinancial Agreement Form

Dr. Erramouspe’s Financial Policy Agreement

We thank you for choosing our office for your dental needs. We realize that every person’s financial situation is different. For this reason, we have worked hard to provide a variety of payment options to help you receive the dental care you need and deserve, that will allow you to enjoy a healthy, beautiful smile with respect to your budget.

To maintain the practice operations and prevent potential misunderstanding, we ask patients to read completely the financial policy for Erramouspe Dental.

By signing the Financial Agreement Form, you accept and agree to adhere to the financial policy, outlined below.  You can down your copy of the Financial Agreement Form by clicking the button above for a PDF copy.

 

PAYMENT IS DUE AT THE TIME OF TREATMENT
PAYMENT OPTIONS:

No Dental Insurance:

You may pay by cash, check or credit card. We accept Visa, Discover and Master Card. We also accept payments made with the Care Credit healthcare credit card.

On extensive treatment, you may elect to pay 50 percent of the total treatment at the
appointment time, and the balance of 50 percent on the delivery or completion date.

You have Dental Insurance:

You are responsible to pay your deductible and or any applicable co-payment on each visit. We will be happy to submit your dental claim to your insurance company. Before you leave, we will determine your approximate co-payment and that amount will be due upon leaving the office. You may pay by cash, check, or credit card.

Some procedures are not covered by dental insurance. It is your responsibility to know what your plan benefits, deductibles and annual maximums are.

Any charge not covered by your insurance is your financial responsibility.

On extensive treatment, you may elect to pay 50 percent of your co-payment on the preparation date and the remaining balance on the delivery/completion date.  

You may pay by cash, check, or credit card. We accept Visa, Discover and Master Card. We also accept payments made with the Care Credit healthcare credit card.

credit_card_logos_9 Online Credit Application