New Patient Information

Your initial appointment usually will consist of a complete oral physical examination and a review of your treatment options. Usually, treatment can be done or started the same day as the consultation. However, a complex medical history or treatment plan will require an evaluation and a second appointment to provide treatment on another day. Please assist us by providing the following information at the time of your consultation:

  •     Any x-rays taken by a previous dentist, if applicable.
  •     A list of medications you are presently taking.
  •     If you have dental insurance, bring the necessary completed forms. This will save time and allow us to help you process any claims.

If for some reason you are unable to do that, you can also download the registration forms to the right.  All three forms will need to be printed, filled out and signed. Please bring them with you to your first appointment or you may fax them ahead of time to 301-735-3062

IMPORTANT: All patients under the age of 18 must be accompanied by a parent or guardian. Please alert the office if you have a medical condition that may be of concern prior to treatment (i.e., diabetes, high blood pressure, artificial heart valves and joints, rheumatic fever, etc.) or if you are currently taking any medication (i.e., heart medications, aspirin, anticoagulant therapy, etc.).

X-RAYS: If your dentist or physician has taken x-rays, you may request that they forward them to our office. If there is not enough time, please pick them up and bring them to our office. If additional x-rays are necessary, they can be taken at our facility.

Click the links below to download each form.

Click the links below to learn about our patient financing options.

What You Need To Do Before Your First Appointment

Dr. Staley-Neither and her staff are dedicated to providing you with a pleasant visit and results that you’re proud to show off. Our administrative staff is ready to help you with questions about scheduling, financial policy and insurance, to make that part of the process as simple as possible.

  • Collect and bring your prior dental records and any x-rays.
  • Bring a list of medications you are presently taking.
  • If you have dental insurance, bring the necessary completed forms and/or ID card.
  • Print and complete all new patient forms as applicable.

Office Policies

Our office has a few office policies in place to ensure a productive and successful patient experience.

Our office wants all of our patients to be able to comfortably afford dental care. We proudly offer the following financial policy so that our patients can have the opportunity to decide which payment option best suits your needs.

Insurance: Our office understands the value of insurance benefits to our patients and will gladly work with you to help get the maximum benefit available to you. We will accept assignment of benefits. We can file claims for any insurance that is not an HMO that requires you to see a specific dentist. Do not confuse a PPO with an HMO. With a PPO you should be able to see any dentist, but your co-payment may be slightly different from those on the insurance company’s list.

Most dental insurance plans do not cover 100% of the cost of your treatment. Because of this and the extreme delay in receiving payment from the insurance, you will be asked to pay your deductible and your portion of your charges the day the service is rendered. We will estimate as closely as possible your coverage, but until we actually receive the payment from the insurance company, it is just an estimate. We will assist you in dealing with your insurance company, but the ultimate responsibility lies with you. After 45 days the balance will be due in full from you. Our estimates are subject to final approval by your insurance company and could therefore change the amount due to or office. Payment of large amounts of co-payment or portions not covered by your insurance can be done using CARECREDIT – an outside patient financing company.

Non-Insurance: Payment for services are expected the day the services are rendered. After determination of the required treatment, we will work with you to sequence treatment and provide payment options that best suit you and that also allow us to provide the best possible care. Our payment options follow below.

The Health Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential.  This Act gives you, the patient, significant new rights to understand and control how your health information is used.  “HIPAA” provides penalties for covered entities that misuse personal health information.

Special Care Dentistry keeps a record of the dental care services that are provided to you.  Our Notice of Privacy Practices describes in detail how your health information may be used and disclosed and how you can access that information.   We will not disclose your record to others (except in the circumstances described in our Notice of Privacy Practices) unless you direct us to do so, unless the law authorizes us to do so, or unless circumstances compel us to do so.  You may ask to see a copy of your record or get more information about it by contacting the office directly. If you find information in your record to be incorrect, you may ask that the record be corrected by writing to the office as well.

We understand that last minute changes in your schedule may be unavoidable and we will try to accommodate those changes as best we can. Please understand that when we make an appointment we are setting aside enough time to do our best work and that each appointment is for only one patient. We do not overbook expecting some of our patients to not show for their appointments. Therefore, a broken appointment without adequate notice results in wasted time for us, adding to the cost of providing care for all our patients.

To be fair, if you have an avoidable conflict and cannot give 48 hr notice to change the appointment, there will be no charge for the first time this happens. The second, subsequent cancellation for the same appointment will incur a fee of $50.00 per half hour of the scheduled time. A third subsequent cancellation of the same appointment will require prepayment of the entire fee prior to rescheduling and the fee forfeited if the appointment is not kept.


Cancellation or rescheduling of an appointment less than 48 hours may or may not be considered a broken appointment; it will be at our discretion.