Patient Forms
Welcome to Our Practice
Thank you for scheduling an appointment with Central New England Endodontics & Implantology. It is our goal to prepare you for your initial visit with us to ensure that your visit is a pleasant one.
So that we may better serve you, please complete the following questionnaires. There are two forms that you may print out and complete in the privacy of your home. Please bring these forms with you when you arrive for your first appointment.
To download the forms to your computer, simply right-click each one and select “Save Target As...” or “Save Link As...”. The forms are in PDF format and require the Adobe Acrobat Reader. If you don't have this program, you may download it for free from the Adobe website by clicking on the icon below the forms.
What is our billing policy?
1. We are a fee-for-service office, which means that payment is expected at the time of service. We will be happy to estimate all future charges for you.
2. Insurance. We will bill your insurance company promptly and directly. If, for some reason, your insurance company does not pay for your visit, the responsibility for payment is yours. Payment of your deductible and co-pay are expected at the time of service. If we are not contracted with your insurance company, we will require a 40 percent deposit. We are happy to assist you with questions regarding your dental insurance.
3. Billing. For patients with dental insurance, we will mail a statement for any unpaid balance after insurance payments are received.
What will you need to bring with you?
1. Insurance card or proof of insurance.
2. If under the age of 18, a parent or legal guardian must be present.
3. Payment: We gladly accept cash, checks and major credit and debit cards. (Third party financing is also available.)
Please pre-medicate if necessary. If you need medication, call your physician prior to your appointment.
We look forward to meeting you and providing your endodontic care. If you have any questions whatsoever, please do not hesitate to call. Our patients are our number-one priority. Following are our telephone numbers.
Worcester: 508-791-5529 or 888-768-ROOT
Fitchburg: 978-345-7555 or 888-769-ROOT
Keene: 603-357-1576 or 888-852-ROOT
Putnam: 860-928-9115 or 877-891-ROOT