Welcome to our office. Useful information is provided below for patients who are new to our office. If you have questions, please don't hesitate to call or e-mail us. We look forward to your visit.
New Patient Forms
If you would like to keep forms to a minimum on the day of your first visit, please print and bring (or mail / FAX) the following forms on or before the day of your first visit. By doing so, you will only need to provide a few items when you arrive for your appointment, such as driver's license and dental insurance card.
Please note that the Adobe form is fillable, meaning that you can first fill out the form on your computer, and then print, sign and bring the hardcopy with you to the office. Alternatively, please feel free to FAX the signed forms to our office. (Because signatures are required, we have not opted for a form that can be emailed to our office.)
Click to download
the New Patient Form Packet
- Fill electronically, Print, Sign
 (If you need the free viewing software, click to download "Adobe Reader" from Adobe's website)
Payment and Financial Options
We ask that payment be made on the day that services are rendered.
Acceptable forms of payment are cash, personal checks, credit cards (Visa, Mastercard, American Express), and Care Credit (see below).
A $50 fee will be charged for any returned/declined checks.
For multi-appointment procedures (e.g., crown/bridge, root canals, implant, cosmetic), 50% payment may be accepted for qualified patients at the first visit, and then the balance payment at the second visit. We offer a 5% discount for full payment of multi-appointment procedures at the first visit (except when payment is made using a dental credit program - described below).
Dental Insurance
Our office accepts most PPO dental insurance plans. (However, our office does not participate with HMO or DHMO plans, as we find that they are generally not designed with the patient's best interest in mind.) Please call or stop by our office with any questions you may have regarding your insurance plan.
At your first visit, your insurance card and an ID will be copied into your file. To ensure efficient and full processing of insurance claims, please provide full dental insurance information over the telephone prior to your first appointment. By doing so, our office will be able to verify your insurance benefits accurately and completely prior to your arrival, to make payment and decision-making more convenient for you or your dependent.
Please note that there is a significant different between most medical insurances and most dental insurances. While patients may be accustomed to paying a flat or fixed "co-pay" for medical services under a medical insurance plan, dental insurance coverage only acts as a supplemental payment and is not intended to act as a comprehensive payment for all services received. That is part of the reason why payments made on the day of treatment is described as "estimates only", based on the information provided by you regarding your dental insurance and dental treatments received outside this office. The actual insurance benefit, and therefore a patient's remaining balance upon being credited with the insurance payment, will only be known after the insurance claim has been processed by the insurance company.
Where insurance benefits can not determined before your appointment, our office may ask you to pay in full for services rendered, and then promptly refund you any balance upon receiving payment from your insurance carrier. At all times, the cost of treatment, whether believed to be covered by insurance or not, is the responsibility of the patient receiving treatment.
If our office does not participate with your insurance plan, as a courtesy, we will provide you with all documentation necessary for your to send a claim to your insurance carrier as well as provide information and answers to questions that you may have.
Also, please note that our office policy is to not accept assignment of benefits for "Secondary Insurance". We will gladly provide all documentation necessary so that you can submit your claim and obtain reimbursement directly from your secondary insurance carrier. In addition to other factors, we have found that processing secondary insurance claims regularly becomes an impossible which can last many months or even years. A large part of this appears to be due to the fact that there are at least four different parties involved (the insured patient, primary insurance, secondary insurance, our dental office.) It has been our experience that the process is greatly simplified by removing the dental office from the various communications and that this typically makes the process much simpler for covered patients.
Dental Credit Programs - Zero interest "same as cash" financing
We participate with CareCredit (a G.E. Company). By offering zero interest ("same as cash") plans for a fixed number of months ("promotional period"), treatment fees can be managed. There is no application fee, and no interest will accrue as long as required minimum monthly payments are made and the account balance is paid off during the promotional period.
Even if financing is not needed, this no interest financing method can be a smart way of managing your finances.
For example, for a $3,000 treatment fee, financing through Care Credit can be established for a period of 12-months (the "promotional period"). During each of those months, minimum payments of $100 can be made, with the balance being paid off in the final month. Alternatively, payments of $250 can be made over the 12-months, which would pay off the balance. In either case, no interest is accrued.
Application & acceptance for these programs takes just a few minutes, and can be completed at home or at our office. From home, an application may be submitted using Care Credit's website. Please feel free to call our office for application related information, such as a recommended "credit limit" amount.
Message From CareCredit: "CareCredit gives you the freedom to get your procedure whenever you’re ready. It’s easy to apply. With three simple steps, including an instant approval process, you can say goodbye to the waiting time and reward yourself sooner."
Missed Appointment Charge
Our office requires 48-hours advance notice (during business hours) in order to cancel an appointment, and will charge a $50 fee for inadequate notice of cancellation or missed appointments. Where a patient is scheduled for multiple appointments, the fee will be charged for each appointment missed.
Our office believes in keeping patient wait times to a minimum, if not zero. Therefore, we afford each appointment enough time to begin and finish on time. Also, our office does not expect patients to miss appointments and therefore we do not over- or double-book appointments.
Since our office will reserve an entire team to your appointment, we ask that you notify us of any cancellation, at least 24-hours prior to your appointment, so that we can try to have another patient take that appointment time. (* Not counting weekend days.)
Also, please note that patients who are substantially late for an appointment may not be seen, and may be deemed to have missed the appointment. We understand that daily life can be unpredictable and will do our best to work with our patients.
This policy helps us to maintain this philosophy of minimizing or eliminating patient wait times, and will benefit all of our patients in the long-run. Your cooperation is greatly appreciated by all of our staff.
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Jamie H. Park, D.D.S.
10680 Main St., Suite 150
Fairfax, VA 22030
Ph. 703-385-4569
E-mail Us
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* Request an Appointment *
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703 . 385 . 4569
