Patient Info

Patient Information

For all your dental care needs, Restoration Dental is here to bring a healthy smile to you and to your family with a modern touch. we place emphasis on preventive care via regular periodical checkups and clean ups to make sure your smile stays healthy. To help you make a well informed decision, we help educate you on what your treatment should consist of.

For more information about our office and services, please visit the following pages:

Please feel free to contact us with questions or if you would like to schedule an appointment.

Patient Forms & Policies

New Patient Forms

New Patient? Complete our Patient Registration form along with our Medical History and HIPPA acknowledgement forms prior to your scheduled appointment:

Download Our New Patient Registration Forms

Download Our Medical History Forms

Download our HIPPA Acknowledgment Forms

Download our Financial Policy here

Download our Appointment Policy Here

Medical History Forms

New Patient? Please complete our Medical History Forms along with our New Patient Forms and HIPPA acknowledgment forms prior to your scheduled appointment!


Download Our Medical History Forms

HIPPA Acknowledgement Form

New Patient? Complete our HIPPA acknowledgment form along with our Medical History and New Patient Forms prior to your scheduled appointment:


Download our HIPPA Acknowledgment Forms

Financial Policy

We attempt to give you an accurate estimate of your total fees prior to starting your treatment. However, due to the nature of dental treatment, there are situations when the treatment may change. We will do our best to inform you about changes to the treatment plan as quickly and accurately as possible. Total payment for services rendered is due at the time of treatment. In order to make payment arrangements as convenient as possible for you, while at the same time maintaining operation of our office in the highest standard of care, we do offer the following payment options:


  • Pre-Payment:Some patients prefer to pre-pay toward their dental treatment. We will be happy to assist you with your pre-payment up to three months prior to the treatment. When you have pre-paid for treatment your check out time is reduced and you are able to go about your day. Please insist on a receipt with every payment you make.
  • Cash/Money Order/Personal Checks: Cash/money order/personal check payments are always welcome.Total payment for the service rendered is due at the time of service. However, there will be a $50.00return check fee for returned checks.Credit/Debit Cards:We accept all debit cards and most major credit cards (Mastercard, Visa, Discover,American Express).
  • Insurance:We will gladly accept, and as a courtesy, bill your dental insurance (if we can verify active coverage). Prior to treatment being rendered you will receive a treatment plan that will be explained to your full satisfaction. Please understand this is an estimate made to the best of our ability based on the information your insurance carrier has provided us. If you are required to pay a co-payment or deductible, it will be due at the time of service. If there is a balance left on your account after your insurance carrier pays, you will be responsible for the balance and you will receive a statement.
  • Payments/Special Financing: Our office also works with Care Credit to assist you with your payments.For qualified applicants, interest-free payments can be spread over a three, six, or twelve month period.

Regarding parents or guardians who are divorced, separated, or single: The parent of guardian noted as the responsible party on the initial new patient form for the child’s account is financially responsible. If the child has a secondary insurance, we will be happy to file(provided we are given all applicable information that we are able to verify). 

However, we are not in a position to mediate payment arrangements between parents/guardians. Any balance over 90 days old is considered delinquent and will be forwarded to a collection agency.

Appointment Policy

Welcome to Restoration Dental. We are so excited to have you as our dental patient. We look forward to taking care of all your dental needs and making you a part of our family. To enable us to provide efficient care we ask for your cooperation with the following guidelines:


  • On Time Arrival – Please arrive at, or just before your appointment time. As a courtesy to others, we reserve the right to reschedule your appointment if you are more than ten minutes late.
  • Late Arrival – If you are running late, please contact the office so we may try and handle the schedule as best as possible. There may be times where we may need to reschedule the appointment.
  • Rescheduling – We require 24 hour notice for rescheduling an appointment. 
  • Cancellations and Missed Appointments: Our goal is to provide individualized dental care in a timely manner. Missed appointments and late cancellations inconvenience those individuals who need access to care. In order to be respectful of the needs of other patients, please be courteous and callus promptly if you are unable to show up for an appointment. If it is necessary to cancel your scheduled appointment, we ask that you call at least 24 hours in advance.

    A failure to be present at the time of a scheduled appointment will be recorded in your medical record. We reserve the right to charge a $50.00 fee for a missed appointment.

It is our sincere hope that we can have a long, friendly, fun relationship with you and your family. If you should have any questions concerning this or any other matters please feel free to contact any of our front desk coordinators at (210) 523-2400. Thank you!


Learn and Apply for CareCredit here!