Patient Information

Patient Information

Personalized Dental Treatments in Cincinnati, OH

Dr. Lali Minocha and our experienced team at Smiles By Design will work closely with you to understand your dental needs and desires, developing a plan together to achieve your goals. We are proud to offer an in-office dental plan and trusted oral health care tips to help every patient maintain optimal oral health and a radiant smile. We also provide emergency services during office hours.

First Visit Information

We will do everything we can to ensure your first visit with us is a pleasant one. During your initial appointment, Dr. Minocha will perform an oral cancer screening, diagnose the health of your gums and bone, and determine what level of cleaning you need. She’ll also look for any broken fillings or new cavities, and take pictures of your teeth that you can see on a computer monitor, so you can understand what’s going on. Your visit will conclude with a teeth cleaning and explanations for any questions you may have.

Interest Free Financing Available

Your dental health is important to your overall health, but we understand that it’s not always easy to afford. That’s why we offer 6 months, 0% financing with convenient payment options. Call us today for more information.

All Major Insurances Accepted

At Smiles By Design, we understand that insurance coverage can be confusing so we’re here to help. Call us at 513-697-7888, provide us with your insurance information, and we will call you back with details regarding your coverage information. We will help you get every penny possible from your insurance company.

By choosing Smiles By Design, you can rest assured knowing you’ll be in and out of our office in no time! We offer a small, private practice setting and family-friendly atmosphere that can’t be found elsewhere. To schedule an appointment, contact us today at 513-697-7888!

In network insurance providers include but are not limited to:

Aetna
Assurant
Cigna
Delta Dental
Dental Care Plus

Dentemax
Guardian
Humana
Superior Dental Care
United Concordia

If you find that you have an insurance that you don’t recognize, it may be linked to an insurance provider above. Call us today so we can help you!

All Major Credit Cards Accepted

For your convenience, we accept Visa, MasterCard, Discover, and American Express.

Patient Forms

Please take a moment before your scheduled appointment to download and complete our patient forms. We look forward to assisting you with all your dental needs.

Patient Health History
HIPPA
HIPPA Privacy Notice Overview

Once you have finished filling the forms, please save the PDF files to your computer. We then ask that you print them out to bring to our office, or emailing the forms as an attachment to: info@smilecincinnati.com

Patient Information


Health Information

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctor at the next appointment without fail.


Employment Information


Insurance Information

Primary

Secondary


Consent for Services

As a condition of your treatment by this office, payments must be made at time of service. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

A return check fee of $25.00 will be assessed to the patient for any insufficient funds claims. It is the patient's responsibility to pay for any rendered services, which have not been paid by their respective insurance provider within thirty (30) days of treatment.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. A service charge of 1½% per month (18% per annum) on any remaining balance after treatment was completed on all accounts exceeding 30 days.

I understand that there are risks with dental treatment, which involves anesthetic, where numbness may persist indefinitely. In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing. I agree to pay all costs and reasonable attorney fees if suit were instituted herunder.

I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to their content.

Signature of patient, parent or guardian:

Signature of guarantor of payment/responsible party: