Patient Info
New Patient Forms
Why wait to fill out these forms in our waiting room when you can fill everything out easily, and at your own speed at home.
Save time before you come in to visit us. Download, print, and fill out these forms at your convenience before your first appointment, and then bring them with you to your appointment. If you have any difficulty filling out or locating all of our forms, please feel free to give us a call. We’re always happy to help.
Main Street Dental Comprehensive Dental Plan
You can afford the smile you’ve always deserved with the Main Street Dental In-House Comprehensive Dental Plan
Why would we ever want to put a frown on your face when it’s our job to make you smile? Even if you don’t have insurance, there is another great way you can afford the smile of your dreams: with Main Street Dental’s In-House Patient Finance Plan.
Main Street Dental’s Comprehensive Dental Plan is designed to provide affordability and greater access in dental care. With your Comprehensive Plan you will have:
- No yearly maximums
- No deductibles
- No claim forms
- No pre-authorization requirements
- Immediate eligibility
Benefit Premiums
| Total Amount Cost | |
| Adult Complete | $331 |
| Child Complete | $276 |
| Perio Complete | $557 |
*The Child Plan is for children 13 years of age and younger.
**The Adult Plan is for anyone 14 years of age and older.
You will not receive a membership card—your plan’s effective date will be on file with our receptionist!
COVERAGE TABLE
Adult Complete
|
2 Professional Cleanings 1 Comprehensive Exam (new patients only) 2 Periodic Exams Routine x-rays 1 Emergency Exam 20% off any Doctor Services |
| Savings of $226.00 per year |
Child Complete
|
2 Professional Cleanings 1 Comprehensive Exam (new patients only) 2 Periodic Exams 1 Fluoride Treatment Routine x-rays 1 Emergency Exam 20% off any Doctor Services |
| Savings of $186.00 per year |
Perio Complete
|
3 Perio Maintenance Cleanings 1 Comprehensive Exam (new patients only) 2 Periodic Exams Routine x-rays 1 Emergency exam 20% off any Doctor Services |
| Savings of $252.00 per year |
Program Exclusions and Limitations
This program is a discount plan, not a dental insurance plan.
It cannot be used:
- In conjunction with another dental plan.
- For services for injuries covered under workman’s compensation.
- For treatment which, in sole opinion of the treating dentist, lies outside the realm of the capability.
- For referrals to specialists.
- For hospitalization or hospital charges of any kind.
- For cost of dental care which is covered under auto medical.
- With senior discount.
This plan is only honored at Main Street Dental. It is not an insurance plan that can be used at any other dental office.
NON-REFUNDABLE
No refunds or premiums will be issued at any if time participant decides not to utilize dental plan.
Plan expires one year from date of purchase.
Insurance & Financing
Our team can help you maximize your insurance benefits to get you the care you deserve
Trudging through the insurance quagmire is beyond frustrating and it takes so much time and effort, so that’s why our practice will help you navigate your benefits to maximize your current insurance plan so you are getting the care you want, and the smile you’ve always dreamed of. Call us today to find out how we can help!
Online Payments
We make paying for your new smile easy!
You can safely and securely pay for your treatment through our online portal. Your information is safe with us. No need to wait. When you’re ready, we can take your payment right here: