Office FormsFor your convenience and to save time at the first appointment, you may download, review, and complete the following forms. Please bring the completed forms with you to the office.
- Get Acquainted Questionnaire [pdf]
- Consent for Examination, Treatment, and Assignment of Insurance Benefits [pdf]
- Notice of Privacy Practice [pdf]
- The Dental Board of California Dental Materials Fact Sheet [pdf] and Comparison of Dental Materials Table [pdf]
Other Forms Available
Please call us at (415) 441-7766 to make an appointment.
If you would like to request an appointment online, please click here. This link will take you to our Demandforce page, where you can make an online appointment request. We will contact you as soon as possible to confirm or reschedule your requested appointment based on availability.
No charge will be made for rescheduling your appointment if a 48 hour notice is given to us so that your child's reserved time can be given to another patient. We do not consider a message left on or with the answering service as a 48 hour notice. You need to contact our office and speak with one of our reception staff during normal business hours.
Every effort will be made to be on time for your child's appointment. However, no one can predict a child's behavior at any one appointment so there may be times that our office will be running behind time. We will sometimes need to rearrange our schedule in order to accommodate a child who has been injured or had an accident.
Please accept our apologies ahead of time should such a delay occur during your child's appointment. Please understand that we will do exactly the same if your child is ever in need of emergency care.
A pediatric dental office just has to run on "Children's Time" sometimes!
- Our fees are based on the actual work provided for your child.
- Payment is required at each appointment as services are rendered and can be made by cash, check, American Express, VISA, or MasterCard.
- Please be aware that whichever parent brings your child to our office is responsible for all co-payments due the day of treatment.
- We cannot send statements to other people.
ChargesCharges may be assessed for the following:
- Broken Appointment: $35 - $50 - $75 - $100 - $150 -$175 - $200 - $250
- Rescheduling Fee: $35 - $50 - $75 - $100 - $150 - $175 - $200 - $250
- Returned Check: $25 + $5 (bank fee) + returned check amount
- Minimum Late Charge (for any outstanding balance): $25 per month
We accept most dental insurance plans and consumer credit cards. Please call us for more information.
Interest free patient financing (Care Credit) is also available through our office to help you meet your healthcare needs. Many patients put off treatments and procedures because they cannot afford to pay. Doctors offer CareCredit payment plans as a convenient option to consumer credit cards, cash or checks. CareCredit allows you to pay over time often without incurring interest charges instead of a lump sum prior to treatment. Offering CareCredit removes the accounts receivable responsibilities from the doctor and allows them to focus on recommending and providing the best care to their patients.
Payment is expected in full at the time services are provided for your child. When this is not possible, Financial Arrangements must be made prior to treatment. Any previous Past Due Family Account Balance must be cleared prior to scheduling any future appointments.