11300 Rockville Pike, Suite 1013
Rockville, MD 20852
(301) 231-9100

New Patient Forms and Information

 

NEW PATIENTS MUST FILL THE FOLLOWING FORMS & BRING TO THEIR FIRST APPOINTMENT:

FORMS NEEDED FOR THE OFFICE NEW PATIENTS:

 

We recommened arriving 15 minutes early to accomodate parking and filling out the necessary forms. Thank you

Please be aware that appointments are time sensitive. If your appointment has been confirmed and you fail to show up there will be a charge. Failure to show up, be medicated or if you decide to leave the facility will result in a charge. Thank you.

A credit card will also be necessary as preauthorization of payment. When the services are rendered the card will be charged out.

ADDITIONAL FORMS FOR OTHER TREATMENTS AT THE OFFICE:

FORMS NEEDED FOR IN-OFFICE WHITENING:

FORM NEEDED WHEN HAVING AN EXTRACTION:


POST OP INSTRUCTIONS:

Extraction(s) (single or multiple teeth)
Dentures (complete and/or partial)
Tooth-Colored Fillings (Composites)/Crown & Bridge

 

 

FOR PATIENT’S FILE
Acknowledgment of Receipt of Notice of Privacy Sheet

PAYMENT INFORMATION

We accept the following PPO insurances in our office, and we would be glad to file claims on your behalf:

For payment, we accept cash, checks, Visa, MasterCard and Discover.

Now accepting patients through "DentalPlan".

Dr. Chaudhary also participates in the DDS Program (Donated Dental Services) through the MSDA (Maryland State Dental Association).

11300 Rockville Pike, Suite 1013, Rockville, MD 20852 USA
Dr. Namita Chaudhary (301) 231-9100 (301) 231-0866 jessica@srsmile.com