Patient Registration Forms
Before visiting our office for the first time, please download, print and fill out both of these forms. They are in Adobe Reader format.
PATIENT REGISTRATION FORMS
A form that includes your medical history and other vital information needed to provide you with the highest level of care.
Consent to endodontic therapy
Information form about the various procedures involved in endodontic therapy and to obtain their consent before starting treatment.
privacy notice
A form that details how your health information may be used or disclosed and how you can get access to that information.
doctor's referral page and Form
Please note this referrals form is for use only by the dental professionals.
Patient Billing
For your convenience we accept Visa, MasterCard, American Express and Discover and Care Credit. We deliver the finest care at the most reasonable cost to our patients, therefore payment is due at the time service is rendered unless other arrangements have been made in advance. If you have questions regarding your account, please contact us at 706-884-3636. Many times, a simple telephone call will clear any misunderstandings.
Please remember you are fully responsible for all fees charged by this office regardless of your insurance coverage.
We will send you a monthly statement. Most insurance companies will respond within four to six weeks. Please call our office if your statement does not reflect your insurance payment within that time frame. Any remaining balance after your insurance has paid is your responsibility. Your prompt remittance is appreciated. We can make arrangements for a monthly payment plan but this must be done prior to the actual procedure.
Financing Available
For those who desire a payment plan or a financing option we have an agreement with CareCredit®. Arrangements for CareCredit should be made prior to your appointment.
Use the link below to learn more and apply.
D.K. Fagundes Endodontics
*Making payments via Pre-Paid Debit Card or Credit Card will result in a 2.99% processing fee. There is no processing fee for making a down payment with a traditional Debit Card.
We defer to the refund policies put in place by D.K. Fagundes Endodontics and cannot initiate a refund without their approval.
Once D.K. Fagundes Endodontics authorizes a refund we will deposit the refunded amount (full or partial) into your account. Your Cherry account status and loan balance are adjusted accordingly.
If a partial refund is issued, your loan amount will be adjusted to reflect your new remaining balance. If a refund is issued in full, any payments made on your loan will be returned to you.
