Below are instructions for you to follow in setting up an appointment. For clarification or additional information, contact our office.
Medicaid Patients with Applied Income
- Complete the Dental Referral form.
- Complete an H1263B form. For instructions on how to do so, click here.
- Read about your rights to privacy under HIPAA and sign your acknowledgement of your rights in our “Privacy Notice form.
- Fax or email Dental Referral Form, Privacy Acknowledgement form, and pages 1-2 of the H1263B form to our office so that we can get prepared to schedule your appointment.
- Mail pages 1-2 of the original H1263B form to our mailing address.
Private Pay Appointment
- Complete our Pay Agreement Form.
- Sign our Acknowledgment of Privacy Notice Form.
- Fax/Mail the above forms to PO Box 122295, Fort Worth, TX 76121. Include a check for the initial exam fee.