Bellevue Impressions Dentistry
Personalized Dentistry For Your Smile
BELLEVUE OFFICE: 425-746-8676

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New Patient Information

At Bellevue Impressions Dentistry we always welcome new patients. Please download, fill out, and bring the patient form with you on your appointment day.

Patient Registration Medical History Form

HIPPA Acknowledgement Form

Statement of Privacy Practices

Office Policies

Credit Card Information Form

Initial appointment will be a consultation explaining diagnosis and treatment options. Occasionally, treatment can be done on the same day as consultation.

Please provide following information at time of your appointment.
  • Referral slip / x-rays if applicable
  • List of medications currently being taken
  • Dental insurance

Financial Policy
Payment is expected at the time services are conducted. Should you need to reschedule an appointment, please provide at least 48 hours notice in order to avoid cancellation fees. We accept cash, check, Visa, and MasterCard. If needed, we can set up financial arrangements.

Payment and Insurance
— Our Courtesy To You...
As a courtesy to you, we will bill your insurance company for you if you provide the necessary and accurate information. However, we remind you that your insurance is a contract between you, your employer and your insurance company. We are not a party to that contract. Accordingly, you are fully responsible for the service fees. Please keep in mind that any pre-estimate that your insurance company provides is not a guarantee that will cover a procedure. However, we promise to do our best to see that you receive your maximum benefits. Your dental coverage is subject to your yearly maximum, your deductible and your eligibility at the time the services are rendered. If you would like to know what your expected coverage will be, we will gladly submit a pre-treatment estimate to your dental insurance.

Co-payments are due at the time of treatment. Please provide any changes that may affect your billing and physical conditions, i.e. employment, address, new medical/ dental problem(s), or insurance coverage.

Payment in full is expected at the time of service, including self-pay patients. Cash, Check and Credit Cards (Visa, Master Card)

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1811 156th Ave NE, Suite #1, Bellevue, WA 98007 | Call: 425-746-8676
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