Patient Forms

patient forms

Patient Forms


Thank you for choosing Bella Smiles Cosmetic and Family Dentistry to care for your dental needs. We are committed to providing you with excellent care and convenient financial arrangements. Our financial arrangements are based on an open and honest discussion of recommended treatment options, respective fees and patient financial arrangements. To confirm your understanding and agreement with our policies, please read:


Payment in full is due at time of service unless prior financial arrangements are made. For your convenience, we offer several payment options:

  • Cash, Debit, Visa, MasterCard, American Express, and Discover
  • Pre-payment Cash Discounts
  • Care Credit and Lending Club Financing
  • Bella Smiles Savings Plan


We welcome dental insurance and accept most dental plans. As a courtesy to you, we are happy to file your insurance claims and assist you in maximizing your dental benefits. We will gladly estimate your expected payment. The patient portion of particular dental service(s) is estimated and due at the time of service. This amount may be subject to adjustment when the dental service(s) claim(s) are adjudicated by the insurance company. The patient is responsible for verifying their benefits and for any remaining balance. Insurance policies vary greatly. Therefore, due to the complexity of insurance contracts, we can only estimate in good faith, not guarantee coverage. As a service to our patients, we will bill your insurance company for service, and allow 45 days for them to render payment. After 60 days, you are responsible for the entire balance and it will be due in full. If you have any questions, our staff is always available to answer them.


When services are planned for minors, the accompanying parent or guardian is responsible for full payment. Responsible party must be present and sign consent at time of all services to minors.


A service charge of 1.5% monthly on unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied. All returned payments due to nonsufficient funds will be subject to a NSF fee of $40 per occurrence. Fees incurred to collect payment will be billed to and payable by the responsible party.


We request 48 hour advanced notice for any change or cancellation of your appointment. Appointments scheduled on a Monday require a 72-hour notice and should be confirmed the Friday before your appointment. We do, however understand that illness and other emergencies occur and we do make exceptions for those rare instances. Our policy is to charge $50 for missed, broken, or no show appointments. Also, if a patient is more than 15 minutes late, there may be a need to reschedule. Repeated cancellations or missed appointments will result in loss of future appointment privileges. Please help us serve you better by keeping scheduled appointments and adhering to the cancellation policy. Thank you for putting your care and trust in Bella Smiles Cosmetic and Family Dentistry.

I (print name) acknowledge that I have read, understand, and agree to this financial policy.



Below you will find all of our office’s new patient registration forms. We will need the completed forms to enter you or your child into our system. We ask that you print and fill them out before your appointment to skip the patient registration process in-office so Dr. Gibson can see you sooner.

Adult Patient Form

If you’re an adult coming in for your first appointment at our office, you will need to complete this new patient form.

Child Patient Form

This form is for children who are new to our office. It must be filled out and signed by a parent or guardian.

Financial Policy

Our office’s financial policy sheet is complete with details about our payment options and financing plans.

If you have any questions about any of our forms or your upcoming appointment, feel free to give us a call at 832-930-7858 today!

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