New Patient Information

New Patient Forms

For your convenience, we are providing forms on this page that new patients—or those updating their information—should fill out and give to Burke Dental. While you may find it easiest to email the forms to us at info@BurkeDental.com, please remember that the information you provide on these forms is your private information and, since the Internet is not a secure medium, the privacy of any email transmission is not guaranteed.

If you have any concern about the privacy of your information when it is sent through the Internet, you have the option of printing these forms out and bringing them with you to your visit. Each button will take you to a PDF form that is formatted to enable you to type your information directly onto the form.

Adult Registration Form

Child Registration Form

Financial Agreement

Notice of Privacy Practices

Records Release Request

Insurance

As a courtesy to you, we gladly submit insurance claims to most dental insurance carriers. We are happy to provide this service and most dental insurance plans will remit directly to our office their portion of payment due. After collecting from you any required co-payments at the time of service, and after receiving any payment from the insurance carrier, we will send you an invoice for any remaining balance, according to your agreement with your insurance carrier.

As a technicality, we want to remind you that your agreement with your insurance carrier is between you and your insurance carrier. Any assistance we provide in terms of filing of insurance papers or confirmation of insurance payments is strictly given as a courtesy and implies no responsibility on our part for follow-up confirmation. If the insurance company does not remit payment within 60 days after the date of service, we will bill you for the remaining balance, which is due and payable upon receipt from you. We are happy to file necessary forms to insure that you receive full benefits of your policy, but we make no guarantee of payments or any estimated coverage.

The benefit provided varies from one insurance carrier to another, and most carriers have several plans within their network, making it nearly impossible for us as care providers to provide you with details about your plan. Therefore it is usually more effective for you to gather details directly from your insurance carrier. When considering an insurance plan, here are some questions you might ask the carrier:

What are my dental benefits?

Are certain procedures excluded from coverage?

Do I have “out of network” coverage for dental care?

What is the coverage for this particular procedure?

How many cleanings per year does my plan cover?

Are there restrictions on the interval between cleanings (i.e., do I have to wait exactly six months, or am I given the flexibility to schedule at my convenience)?

Is preauthorization required for this particular procedure?

Financing

We are proud participants with CareCredit, a third-party financing service allowing interest-free payments for qualifying patients and treatment plans. Because CareCredit is an independent third-party service, we have no direct control over the application process or any terms of an agreement between you and CareCredit.

Please visit www.CareCredit.com for more details. Feel free to contact our patient care coordinator at our office if you have any questions about our participation with CareCredit.

Click here to apply for financing with CareCredit

Input the main text content for your module here.

Click here to check your rate today! No impact on your credit score! Click Now to Get Started with GreenSky