Jared Cox

Adult New Patient Form

Please complete this form. If you have questions, give us a call. We are happy to help! 

Personal Info
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Insurance Info
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Medical Info
Emergency Contact
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We will provide you with good faith estimates based upon the information your carried provides to us about your policy. Please be aware that insurance carriers never guarantee payment according to the percentages they advertise to you, and they adjust their payments according to the fine details contained within your individual contract. After we submit your claim, your insurance carrier will review it to determine how much it will pay for your dental services. If your carrier pays more than we estimated the overpayment will be used to reconcile any family account balances do. If there are no account balances due, we will issue you a refund after all pending insurance claims have been received.

TFD estimates are good for 60 days after they are given. Please be aware that your insurance policy has a limited amount that your carrier will pay each coverage year for all your dental services. If you were seen or will be seen by another dentist in the current coverage year or if your treatment will require a referral to a specialist’s office, your coverage may be exceeded, and your estimated patient portion quoted on your estimate may be incorrect. Please be aware that TFD cannot attain accurate information from your insurance carrier about dental services provided by a previous dentist or specialist. If your carrier denies or downgrades your claim because your annual coverage limit has been exceeded or for any reason, your account with us will be adjusted according to the insurance downgrade and you will be responsible to pay the balance due in full within 30 business days.

Inside Main Street Medical Center . 400 S. Main Street, Suite 300, Searcy AR 72143 . 501-268-3223