Samuel L Corey, DDS             10216 Dupont Circle Drive East  Ft Wayne  IN  46825                         (260)-489-0078

SLC HI-TECH & Cosmetic Dentistry

Patient Forms


There are printable (PDF) forms located in the right column:


  • New Patient
  • Medical History
  • Hippa Notice of Privacy Practice
  • Insurance Release and Financial Form
  • Hippa Permission to share


Please bring your filled in forms with you to your appointment.


Thank you.

Insurance:


We fill out the patient's claim forms and submit them at the time of service. (Although each insurance policy is different, generally insurance providers cover almost 100% of preventative care, 80% of restorative care, and 50% of major dental work.) We ask that the unpaid (co-pay) portion of the patient's charges be satisfied at the time of service.