Patient Information

New Patient Forms

For patients who will be seeing us for the first time, we have made our new patient forms available here for you to download. Completing your forms before you arrive will help us reduce your wait so you can see Dr. Pomerance sooner. If you have any questions about our forms, or you have trouble downloading them, simply give us a call.

New Patient Form

Medical History Form

Oral Cancer Screening Consent

HIPAA Authorization

HIPAA Acknowledgement

Financial Policy

We are privileged you have chosen us as your dental care provider. We are committed to providing you and your family with quality patient care. The following is a statement of our Financial Policy, which you need to understand prior to treatment. If you have any questions please feel free to ask us.

FULL PAYMENT IS DUE AT TIME OF SERVICE. We accept cash, checks, and most major credit cards. There will be a $25.00 fee on all returned checks. Also, we reserve the right to charge for appointments cancelled or broken without 24 hours advance notice.

If your account balance should go past 90 days and it is submitted for Collections, you will be responsible for reimbursing the dental office for the collection fee.

Regarding Insurance

Your insurance policy is a contract between you and your insurance company. We have no control over their decisions and the amount they decide to pay. However, as a courtesy to our patients, we will file your primary claims for you.

Before treatment, we will verify your coverage and calculate your deductible and co-payments as accurately as possible. Please understand that all treatment plans given are only an estimate based on the information your insurance company provides. All deductibles and co-payments are due the day the treatment is rendered.

Please be aware that your insurance company does not guarantee payment over the phone. We will not know the exact amount they will pay until they respond to the claim. REGARDLESS OF WHAT YOUR INSURANCE COMPANY PAYS, YOU REMAIN FULLY RESPONSIBLE FOR PAYMENT OF YOUR BILL.

Once a payment is received on your claim, we will send you a bill for any remaining balance on your account.

Call our office to schedule your next appointment with Dr. Pomerance. We offer comprehensive general, cosmetic, and restorative care to patients from Denton, Corinth, Highland Village, Little Elm, and all across Denton County.