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Little Rock Office
12419 Cantrell Road
Little Rock, AR 72223
(501) 223-8442
(501) 224-2900

Benton Office
1226 Ferguson Drive, Suite 2
Benton, AR 72015
(501) 778-7475
(501) 778-7120

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PATIENT INFORMATION FORM:
Please help us be prepared for your first appointment by completing this Patient Information and Medical History form. Download the form below (in PDF format) to your computer, print it out, complete the form, and bring it with you to your first appointment.

>Patient Form  [PDF]

Download the free Adobe Acrobat PDF Reader
Your First Visit
At their first visit to our office, our patients meet with one of our new patient coordinators, Marquina or Kellie, and with Dr. Daniel.  At that appointment Dr. Daniel takes a brief look at the patient's teeth, discusses what he feels the best treatment options are, and answers any questions the patient or parents may have.  Marquina or Kellie will give the parents a folder with information about the treatment plan and fees, and answers any remaining questions.

Diagnostic Records Appointment
When the patient comes into our office for Diagnostic Records, this typically includes impressions for study models of the teeth, photos of the patient's face and teeth, and X-rays.  This information is used to develop a custom treatment plan for each patient.  These records are also helpful in tracking the progress of treatment as the teeth move while under orthodontic care.

Start Date
At this appointment the patient receives their appliances (braces, expansion appliances, retainers, etc.). It usually takes from one to two hours.

Regular Appointments
We see our patients for regular office visits every six to eight weeks.  The adjustments take 30-45 minutes.  Our regular office hours are Monday through Thursday from 7:30 AM until 5:00 PM.  Patients are seen by appointment only.  We make every effort to be on time for our patients, and ask that you extend the same courtesy to us.  If you cannot keep an appointment, please notify us as soon as possible.  Please cancel only if it is unavoidable.  It is difficult to reschedule appointments since most appointments are made eight to ten weeks in advance.

Payment & Office Policies

Cost
The cost of treatment depends on the severity of the patient's problem, and the amount of time it will take to correct the problem.  We will discuss all fees at the first exam appointment.  Please remember that each patient has different needs and treatment options, so fees will vary from patient to patient.  We accept assignment from most insurance plans with orthodontic benefits, and file the necessary papers with the insurance company.  We work hard to make orthodontics affordable.

Fees
In an effort to keep orthodontic fees down while maintaining the highest level of professional care we have established this financial policy:
  • If full payment is made at the onset of treatment, we will offer a fee discount.  (If you have insurance, we will offer a discount for payment of your portion of the fees that will not be covered by insurance.)
  • To fit your individual needs, financial arrangements can be made to extend your payments on most of our services, over a period of months.
  • For your convenience, we accept payment by VISA, MASTERCARD, and AMERICAN EXPRESS.
  • In cases of serious delinquency, treatment will be discontinued, although we will make every effort to accommodate patients with temporary difficulties.


Insurance
If you have orthodontic insurance, we will help to determine the coverage you have available by filing a "pre-determination of benefits".  We ask that you assign your insurance benefit to us.  The balance will be arranged for you to pay (see above).  Professional care is provided to you, our patient and not the insurance company.  Thus, the insurance company is responsible to the patient and the patient is responsible to the doctor.  We will help in every way we can in filing your claim and handling insurance questions from our office on your behalf.


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