To prepare for your next appointment at PGS Dentistry, please complete the following patient forms. You can complete the forms online and they will be emailed directly to us.
Having this paperwork completed prior to your visit will minimize your wait time and make your appointment more convenient for you. Should you have any questions about our forms or our dental care in Richmond, Romeo, Marysville, or Chesterfield, please call or visit our offices.
Fill out form directly on our website
and submit electronically.
Adult Health History (Adults 18 and over)
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Child Health History (Children Under 18)
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Thank you for choosing PGS Dentistry for your dental needs. Dental treatment is an excellent investment in your medical and psychological well-being. Financial considerations should not be an obstacle to obtaining this important, life-enhancing care.
Our dentists, Dr. Slanec, Dr. Pradko, Dr. Gallagher, Dr. Gadioli, Dr. McCloskey, Dr. Langolf, Dr. Conley, Dr. Myers and our team members are always available to answer your questions and/or assist you in any way we can.
For our patients with dental insurance, our dental insurance professionals are happy to assist you in filing the necessary forms to help you receive the full benefits of your coverage.
The insurance relationship constitutes an agreement between the carrier and the patient. As such, we can make no guarantee of estimated coverage or payment. However, please know that we will do everything possible to see that you receive the full benefits of your policy.
Payment is due as services are rendered. We cannot guarantee your exact insurance coverage. There may be a balance remaining after insurance reimbursement. As forms of payment, we accept cash, personal checks, and credit cards (Visa, MasterCard, American Express, and Discover). Insurance estimates given by our office are not a guarantee of payment. By accepting treatment, the patient or responsible party assumes responsibility for all charges incurred.