New Patient Forms & Helpful Information

All of our new patients at Klamath Dental Center are encouraged to come prepared. Please print and fill out the new patient paperwork forms and bring them with you to your first visit. It is a timesaver for you and our office. Please do not hesitate to contact us if you have any questions. Thank you very much.

New Patient Paperwork

New Patient Forms & Helpful Information

New Patient Paperwork

Perfume Free Office

Klamath Dental Center offers a perfume and fragrance free office. Many individuals and some of our staff are allergic to perfume. We instruct all our patients and staff to come to our office perfume free.

One reason we love our building so much is that our treatment rooms have windows that can be opened in case a patient forgets and applies some perfume. If you are perfume sensitive, you will find our office safe and comfortable.

We also take a special care to make sure all our products are perfume free for your comfort and safety.

Healthy Smiles Program

We are excited to offer an innovative In-Office Membership Dental Plan that allows you to get the preventive care you deserve, which can help eliminate costly problems later.

When you come in, ask for the Healthy Smiles flier and consent form! You can apply on your first visit or any time you come see us!

Benefits
- 2 preventative* dental cleanings with one adult fluoride treatment per year, including a comprehensive exam, a 6 month recall exam and any recommended x-rays per plan year. Children also receive fluoride at each cleaning.
- This plan also allows for up to one emergency exam and x-ray (during normal office hours) per year. All diagnosed dental treatment completed within 12 months of enrollment will be discounted 20% based on method of payment received
Annual Cost
- Individual Adult Plan; $395 (estimated value of $750.00, up to 20% off treatment needs)
- Individual Child Plan: $270 (estimated value of $560.00)
*Periodontal treatment (Periodontal scaling's, Debridernent, and or other advanced periodontal care) and additional periodontal maintenance cleanings will be billed at the regular fee minus the plan discount.

There is NO annual maximum, NO deductible, NO waiting period; NO preauthorization and cosmetic dentistry is included! Your effective date is the day you sign up and your renewal date is the same date every year.
Exclusions & Limitations
- This is a dental discount membership plan and is NOT dental insurance
- This cannot be combined with other discount plans or dental insurance
- The discount applies only to treatment, not over the counter products
- It is good only at Klamath Dental Center, with Arthur R. Belsky D.D.S. Therefore, if you are referred to a specialist, they will not give you this discount
- Should there be any treatment needed following any type of injury and outside medical, auto, disability, or workman's comp type insurance is involved, this discounted plan cannot be used.
- This plan is non-refundable. No refunds are given if the patient chooses not to use their plan within the year after it is purchased. The yearly cost is subject to change at renewal.
- All payments are due at the time of service to receive a 20% discount, if you chose to extend your payment for treatment by paying through Care Credit or a bank card, the restorative treatment discount is reduced to 10% due to merchant fee
- This offer cannot be combined with any other discounts
- Plan fees are valid only when paid at time of enrollment
- Lapse in coverage will be subject to a $50 renewal charge

Insurance & Payment Options

Klamath Dental Center accepts and are happy to bill most major insurance plans, however we are unable to be In-Network with every insurance carrier. Please call if you’re unsure if we take yours. We'll be happy to help you with your dental insurance. Bring your insurance insurance card to your appointment to help us determine your maximum benefit. Unless prior agreements have been made, we ask that you pay the noncovered part, or copayment, at the time of service.

We are pleased to offer CareCredit, North America's leader in patient payment plans, to our patients. CareCredit is here to assist you in paying for dental treatments and procedures that are not covered by your insurance. They provide no-interest financing and low-minimum monthly payments so you may obtain what you want when you want it.

Visit www.carecredit.com or call our office for additional information. Are you ready to apply? Now is the time to apply for your CareCredit card online.