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.


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.