Forms

 

Our Oral Surgery Consent and Denture Policy forms are PDF's with links below, which will download and then you can fill out and print prior to your appointment.

 

Below them is a link to our interactive Patient Information form, which you fill out and submit to us over our secure connection prior to your appointment.  All information you provide will be strictly confidential and secure.

Patient Information & Forms

Financial Policy

  • For your convenience, we accept Visa, MasterCard, Discover, and Care Credit.

  • We also accept cash, and checks with appropriate identification. We deliver the finest care at the most reasonable cost to our patients, therefore payment in full is due at the time service is rendered. If you have questions regarding your account please contact us.

  • 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. 

  • Please remember you are fully responsible for all fees charged by this office regardless of your insurance coverage

 

Limited Warranties

Composite Fillings

Composite fillings are used to fill the hole of a cavity after decay is removed. The ideal composite filling is no more than 50% of the tooth. Sometimes we place a filling thinking there is enough tooth to the hold the filling when actually there is not. The tooth then breaks away because it can no longer support the filling. In this case a crown is indicated.

 

Our Composite Filling Limited Warranty will:

  • Credit the cost of the filling towards the cost of a crown when indicated.

  • Replace the composite filling due to breakage, misfit or decay at no cost for a period of 3 years from the date of service.

  • This warranty is null and void if the patient does not maintain 6-month continuing care cleaning appointments. 

 

Silver Fillings

Silver fillings are used to fill the hole of a cavity after decay is removed. The ideal composite filling is no more than 50% of the tooth. Sometimes we place a filling thinking there is enough tooth to the hold the filling when actually there is not. The tooth then breaks away because it can no longer support the filling. In this case a crown is indicated.

 

Our Silver Filling Limited Warranty will:

  • Credit the cost of the filling towards the cost of a crown when indicated.

  • Replace the silver filling due to breakage, misfit or decay at no cost for a period of 3 years from the date of service.

  • This warranty is null and void if the patient does not maintain 6-month continuing care cleaning appointments.

 

Root Canal

Our Root Canal Limited Warranty will:

  • Refund the cost of a root canal due to failure for a period of 3 years from the date of service.

  • In case the tooth cannot be saved; the cost of a crown placed in our office will also be refunded during the same 3-year period.

  • Refer you to an endodontist who specializes in root canals and why they fail.

  • This warranty is null and void if the patient does not maintain 6-month continuing care cleaning appointments.

 

Crown or Bridge

When choosing a crown, it is important to take into consideration whether to have a gold or porcelain crown. Gold crowns never chip. Approximately 1 in a 100 porcelain crowns chip and need replacement.

If you porcelain crown chips within the first 5 years, we will replace it free. After 5 years, the cost of replacement will be your responsibility.

 

Our Crown or Bridge Limited Warranty will:

  • Replace the crown or bridge due to breakage, misfit, or decay at not cost for a period of 3 years from the date of service.

  • This warranty is null and void if the patient does not maintain 6-month continuing care cleaning appointments.

 

Premium Dentures

Our Premium Denture Limited Warranty includes:

  • 5-year guarantee against tooth loss.

  • 5-year guarantee against breakage.

  • No charge for adjustments for 5-years.

  • Does not include relines.

 

Custom Dentures

Our Custom Denture Limited Warranty includes:

  • 3-year guarantee against tooth loss.

  • 3-year guarantee against breakage.

  • No charge for adjustments for 3-years.

  • Does not include relines.

 

Basic Dentures

Our Basic Denture Limited Warranty includes:

  • No charge adjustments for first 30 days.

  • Adjustments after 30 days are $10 per adjustment.

  • Does not include reclines.

 

Make Your Smile an Audubon Smile!

© 2019 Audubon Dental 

Designed by Wellness Communications

716 Second St., Henderson KY    (270) 827-5222