For our Patients

Paperless forms

We are so pleased to offer our patients the ability to utilize our HIPAA compliant electronic health records  portal so that you can submit the most detailed, current and accurate information from the convenience of your home.

Please read complete ONLY the applicable form for your child’s upcoming visit by clicking the link below:

Form A – Annual Updates – Current Patients – To be completed annually by ALL current patients to keep the medical and demographic information up-to-date.

Form B – Child Dental or Lip tie/Tongue tie Consult – To be completed for children above age 1 year coming to us for dental concerns as well as Lip tie and/or Tongue tie related difficulties – speech, feeding, sleep, behavioral or dental concerns..

Form C – Infant Lip tie/Tongue tie Consult – To be completed for babies less than age 1 year of age coming to us for feeding difficulties.

Form D – New Dental Patient Child Form or Comprehensive History Form for Returning Patients – To be completed for children above age 1 year and coming to us for any of the following scenarios: 1) First visit to Smile Wonders, 2) Previous infant patients that are now returning for their age 1 dental visit, 3) Patients that are returning back to us after having transferred care to another provider, or 4) Patients that have not been to our practice for more than 3 years.

Form E – Additional Child New Patient Form or Sibling New Dental Patient Form – To be completed for any additional children that are joining our family as dental patients. Please complete this form only if other demographic and financial/insurance information is the same as another child that is already a current patient at Smile Wonders.

Pro Tip #1 Remember to close out the window after submitting each child’s form.

Pro Tip #2 Please share notes or x-rays from other specialists, care providers or previous dentists to 🙂

Alternate Adult Representation Form

Click to Submit Online

Patient Record Release Form

Click to Submit Online

HIPPA Practices

Click to download

Payment Options

At Smile Wonders, our mission is to be the gold standard in comprehensive and collaborative care for ALL of our patients. Payment is requested on the day of service and whether your needs are large or small, we are here for you!

Cash, Credit Card or HSA

Our patients pay at the time of services being rendered via Cash, Visa, MasterCard, Discover, American Express as well as HSA (Health Savings account).


Our patients utilize Out-of-Network benefits from their Dental and Medical plans as applicable for services at Smile Wonders.

We are not an authorized or certified provider for Medicaid, Tricare, Kaiser, DMO or HMO plans. Per the limitations set forth by these plans, if patients use a non-network dentist, they will be responsible for all payment and unable to get reimbursed through the insurance provider. Subscribers or beneficiaries of these plans have the options of receiving care with another Provider in a certified facility. Smile Wonders does not discriminate services based on third party coverage or insurance plan level allowances. Care at Smile Wonders is available to all patients on a self-pay basis.

Dental Insurance

We understand that many of our patient families would like to utilize out of network dental benefits. We are happy to help you in the process.

Please provide all the required information on the pre-appointment paperless forms. We will help submit your claim with applicable narrative explanations of treatment and images electronically on your behalf. We have enjoyed great success with maximizing coverage for our patients within the limitations of their individual policy.

Medical Insurance

We understand that many of our patient families would like to utilize out of network benefits from their medical insurance for infant frenectomy procedure. We are happy to help you in the process.

On the day of the procedure, if you let us know in advance, we can prepare a letter of medical necessity that has the pertinent Diagnosis (ICD-10 codes), Treatment (CPT codes), Narrative explanations and fees that can be submitted along with your claim. We will also provide an itemized receipt of payment so that the reimbursement can come directly your way.

Insurance Facts

IF you would like to prioritize only insurance-oriented care here are some facts for you to consider:

Fact #1 Since Covid-19, we have found that many insurances have reduced their ‘coverage amounts’ and implemented many obstacles of strict limitations, exclusions, waiting periods and plan deductibles.

Fact #2 Please know that a customer service rep that usually does not have any medical or dental background and is located in a completely different part of the world is responsible to determine the eligibility for services. They simply follow numbers and codes. They do not understand the level of care needed for your child.

Fact #3 The usual and customary rate (UCR) is determined by each individual insurance company. Subscribers are unaware that since 2020, many companies have categorically reduced their reimbursement by as much as 20% without any reduction of premiums from their subscribers. Reimbursement levels are most influenced by profitability of the insurance companies, rather than cost of living and fees relative to the region, let alone expertise of the provider or your child’s specific needs.

Patient Financing

In order to make oral health affordable and comfortable, our office has partnered with a PatientFi for financing options. It is medical loan that does not require hard credit check and allows for no interest financing for up to 6 months. Please click the link below to find out more and obtain pre-approval.

Our team has many years of experience

Although we cannot make any guarantees when it comes to insurance payments and estimates, we will do our best to share our knowledge and experience with you to help you maximize your reimbursement. Please reach out to our friendly professional staff for any questions at all.

Habit Fairy Calendar

Click to download

Brushing Chart for Kids

Click to download

Tooth Eruption Chart

Click to download

Space Maintainers

Click to download