• Patient Information

  • Responsible Party

  • Dental Insurance

  • * We accept all dental insurances, with the understanding that any portion not covered by the patient's insurance is to be the patient/responsible party.

  • In Case of Emergency

  • Medical History

  • Women:

  • Dental Background

  • Here are some things we would like to learn about you and discuss during your first visit. These are issues you may have never thought about. Please mark all the items that you have or have had.

  • Joint Dysfunction

  • Headaches

  • Sleep

  • Your Smile

  • Recommended Oral Cancer Exam

    Our practice continually strives to provide important enhancements in oral health for our patient. We are concerned about oral cancer and look for it in all at risk patients.

    Oral cancer is a silent killer and the maximum survival is five years. One person dies every hour from oral cancer in the United States.

    Late detection of oral cancer is the primary reason that mortality rates are so dismal. As with most other cancers, age is the primary risk factor for oral cancer. Though tobacco use is a major predisposing risk factor, 25% of oral cancer victims have no lifestyle risk factors.

    Increased risk:

    • 18-39 years of age combined with any of the following Tobacco use
    • Chronic alcohol consumption
    • Oral HPV infection

    Highest Risk:

    • Patients age 65 and older with lifestyle risk factors.
    • Patients with history of Oral Cancer

      25% of oral cancer occurs in people who don’t smoke and have no other risk factors. Early detection is a key to successful treatment.

    We find that using Velscope plus along with a visual oral cancer examination improves our ability to identify suspicious areas that may have been missed during the conventional examination. Early detection of precancerous tissue can minimize or eliminate the potentially disfiguring effects or oral cancer and possibly save your life. The Velscope is a painless exam that gives us a better chance to find any oral abnormalities you may have at an early stage.

    Dental insurance might not cover the Velscope exam. However, this office is happy to verify with your coverage for you. The fee for this enhanced examination is $48.00.

  • Financial Agreement

    I/We understand that I am /we are responsible for all charges incurred within fifteen (15) days of request for payment by Deldar Dental (Dr. Mike and Dr. Sara Deldar).

    In consideration of the services to be provided to the customer/patient, I/we hereby guarantee payment in full of the customer's account in accordance with the financial arrangements made at the time of service/purchase or, if no such arrangemtns are made, in event of default in payment, reasonable collection agency fees up to thirty-five (35%) percent of the delinquent balance and reasonable attorney fees, shall be added to the amount due on the account, plus any applicable court costs.

    By providing my phone number, I give prior express consent to receive calls and text messages from the creditor or its third party debt collector at that number, including calls and messages made by using an auto-dialer or pre-recorded message.

    Deldar Dental accepts cash, check, Visa, MasterCard, and Discover; Deldar Dental also works with outside financing companies to help you to afford your treatment upon our approval.

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