To Our Patients,
We strive to provide the best possible dental and cosmetic care for our patients. Dr. Blake and his friendly staff will be comforting and sensitive to your dental needs.

To familiarize you with our practice and simplify your registration, we have prepared this introductory information for you. We want our financial relationship to be comfortable and convenient for you. We intend for your experience with us to be as pleasant as possible.

BlakeAesthetics participates in many dental payment plans. To ensure that your dental plan provides the proper payment for your care, it is important that you;

• Become familiar with the specifics of your dental payment plan.
• When necessary, obtain prior approval from your dental plan. Your insurance card identifies the telephone number for prior authorization.
• Bring your insurance card to each visit so that your dental care can be accurately reported.
• Promptly notify us of any changes in your address, employer, or dental/healthcare plan so your records are accurate.

At the time of your visit for services, we must collect the following from you:

• Your co-payment and the balance of your health plan deductible,
• Any co-insurance payments required,
• Full payment for supplies or services your dental plan does not cover,
• If you are uncertain of your co-pay and deductible responsibilities, you will be responsible for 20% of the total charges for your visit.
• If you have no dental insurance, you will be responsible for 1/3 of your charges with the balance due in 60 days.

Payment for services can be made with cash, check, or credit card (we accept Master Card, Visa, or Discover). Please come to your visit prepared to fulfill your payment responsibility.

The following form can be downloaded, printed and filled out for your first visit. Please note that there is a Patient Information portion along with the Medical and Dental History portion.

When your information is complete, we can assist you in processing your insurance claims. For questions, please contact us at (260) 747-5745. We look forward to meeting you.

Sincerely,

Dr. Thomas R. Blake and Staff