Thank you for choosing Allendale Dental

Please print out the forms below, fill them out and either bring them to your appointment or fax them to us at 610-265-3964. If you have any questions, please don’t hesitate to contact us or call our office at 610-265-3311.

Forms
• New Patient Information
• New Patient Agreement
• HIPAA NOTICE

Premedication

Payment Policy

Payment is due at the time of service. Any balance that is past 30 days will have a 1% finance charge applied to it.

If you do have insurance, our office will be happy to let you know what your estimated balance for the day is. Any amount unpaid by the insurance is your responsibility.

We send out your insurance claim forms as a courtesy to you. The insurance company has a contract with you, and you are solely responsible for all the charges.

We accept payment by:

Cash

Check

Debit Card

Credit Card

Appointment Cancellation Policy

We do require you to call us 48 hours in advance, to cancel your appointment please call 610-265-3311.

Emergency After Hours Care

If you have a dental emergency, and you have called our office at 610-265-3311 after hours, leave a message along with a working phone number where you can be reached. Please disable your caller ID block so that Dr. Goyal is able to return your phone call.