Office HoursM - TH: 8 am - 5 pm, Select F: 8 am - 12 pm

New Patient Information

What to bring to your first appointment:

Bring your smile!  Also, remember to bring these things with you to your first appointment with us:

  • Your insurance card
  • Your photo ID
  • Completed Patient Forms

You can save time by completing all Patient Forms prior to your appointment. You need to download all of the forms, print them off, fill them out, and bring them with you to your appointment.

Download New Patient Forms Below

To complete forms online and send you will need to have Adobe Reader installed on your device. Simply open the PDF form in Adobe Reader, then you can fill it out. Once you are done, you can click “submit” and it will use your webmail/or computer email to send it to us. Alternatively, you can just print it out and bring with you during your appointment if you like.

CLICK ON EACH LINK BELOW TO DOWNLOAD FORM

New Patient Registration

Medical History

HIPPA Form

Dental Records Release

Financial Agreement

Appointment Policy Agreement

Financial Information

Your smile is yours forever and we want to make it as easy as possible for you to receive the best dental care possible.

Our practice accepts most major credit cards and insurance plans.

If you belong to a traditional insurance plan, we can assist you by filing your insurance claim. Traditional insurance is typically one in which you can choose any dentist you desire. Your dental insurance is based on a contract between your employer and the insurance company. We will make every effort to estimate your dental benefits to the best of our ability; however, this is an estimate only.

Our office team is available to help you with insurance claims and paperwork. Please let us know if you have questions about your insurance coverage.

Financials. Multiple ways to pay…

It is our primary goal and responsibility to help our patients obtain good dental health. We wish to direct our time and energy toward obtaining that goal. We have prepared this letter so that you may be aware of our financial policy. Payment options include the following:

 

  • Cash
  • Personal checks
  • Visa, MasterCard, Discover and American Express
  • Care Credit

 

Payment in full is expected at the time of treatment. Patients with dental insurance must provide accurate and complete insurance information. We will be happy to file for your insurance benefits as a courtesy to you. The estimate that we give you and collect the day of the procedure is only that, an estimate. Dental insurance plans vary and it is our courtesy to estimate as close to possible the amount owed by the patient and the insurance company. It is not uncommon for insurance companies to change covered procedures, fee schedules and reimbursement rates, resulting in additional amounts owed by the patient.

Although rare, some insurance carriers will not reimburse our office directly. In such instances, you will be responsible for the full cost of each visit at the time services are provided, and your insurance company will send you the reimbursement check directly.

We are in network with many dental insurance companies. The best way to know for sure is to call your insurance company and ask them if Dr Ann Kirol is in your network.

We will accept and file all out-of- network PPO plans. Often out-of-network plans cover the same as in-network plans for preventative appointments. However, it is the responsibility of the policy holder to be aware of what benefits their plan does and does not have. We will do our best to share this with you as a courtesy.

Our office does not determine your dental benefits. Our relationship is ultimately with you and not your dental insurance company. Your dental insurance is a contract between your employer and the insurance company. The percentage covered for each procedure is determined by how much your employer has paid for coverage. Most plans routinely pay between 50-75% of the average total fee. We want to provide our patients with the finest treatment available and base our treatment recommendations on what will be best for you rather than what your insurance company does or doesn’t pay. Our primary goal is to provide you with the best possible treatment in a safe environment, using high quality supplies and medications. Unfortunately, the goal of many insurance companies is only to treat patients in the cheapest manner, not necessarily the safest or most effective. At your appointments, you will be responsible for your portion of the fees not covered by your insurance and payment is expected at the time of each service. We will be happy to assist you in estimating your portion of the cost of treatment, but we would strongly recommend you become familiar with your insurance benefits ahead of time.

Prior to completing any restorative treatment, we will provide you with a cost estimate of our total fee, your estimated insurance coverage, and your estimated out-of-pocket costs. Please remember, these are only estimates and may change during the course of treatment. Sometimes, treatment alternatives become necessary for various reasons, which may increase or decrease treatment costs. Any amount not covered by your insurance company is payable at the time services are rendered. These fees may include deductibles, co-payments or certain procedures not covered by your insurance policy. For your convenience, we accept cash, personal checks, care credit and most major credit cards. Any returned checks will incur a $50 processing fee. We cannot accept responsibility for negotiating a disputed claim and allow a maximum of 45-days for your insurance company to clear account balances. If your insurance does not pay within 45 days of the treatment rendered, we shall expect payment in full from you. A late charge of 1.5% per month, or a minimum late charge of $30.00 will be added to unpaid balances over 45 days past due. After 90 days from the time of service and attempts to collect outstanding funds anyone not fulfilling their financial obligation will be sent to collections.

If you have any questions, we will be happy to assist you. We look forward to beginning a wonderful relationship with you! Please do not hesitate to call.

 

Thank you

For those without dental insurance, we offer an in-house dental plan.

You’ve Come To The Right Dentist!

Visiting our Rock Hill dentist office on a regular basis is the best alternative to keep your teeth and gums healthy and your smile bright! The American Dental Association recommends that you, and your child, visit the dentist every six months for regular checkups and routine teeth cleanings. We hope to see you every six months to make sure that your smile is staying healthy!

We value your time and understand you have a busy schedule. We strive to make your appointment informative and efficient. When preparing for your initial appointment, please allow approximately 80 minutes.Your new patient appointment will entail the recording of a variety of diagnostic records. This includes: x-rays, photos, and periodontal readings (gum measurements). Please be assured that our state-of-the-art x-ray technology and protective techniques offer the minimal amount of radiation exposure.

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