World Class Endodontic Care

Right here in Central Illinois

Office Referral

Office Referral

  • MM slash DD slash YYYY
  • :
  • (*May require consultation prior to treatment)

Patients with Dental Insurance:
Dental insurance is a contract between the insured (patient) and the insurance company. As a service to you, we will submit the claim to your insurance company. Your co-payment, which is an ESTIMATE of the total fee, is due at the time of treatment. The patient (or guardian) is responsible for any balance due after the claim has been paid by the insurance company.

Due to Delta Dental’s policies, all Delta Dental patients are required to pay in full at the time of service.

Patients without Dental Insurance:
Full payment is due at the time of treatment.

To submit your claim we need:
1.) Insured’s dental insurance card
2.) Insured’s Social Security number
3.) Insured’s date of birth
4.) Medical insurance card if your general dentist has told you that you may need surgical endodontic treatment

To change a scheduled appointment:
Call our office as soon as possible.

Download Referral Form