Forms and Payment

Payment For Dental Services

We make every effort to keep down the cost of your dental care. You can help by paying upon completion of each visit. Other arrangements can be made with our Office Manager depending upon special circumstances. We will give you an estimate of charges for any procedures or surgery you may require after each consultation, and/or upon request.

If you have dental or medical insurance we will be glad to fill out the proper forms. Dr. Specker is a member of Delta Dental’s PPO plan (not their HMO), and the office will also bill most patient’s dental PPO carrier. Care Credit is also a way for you to pay for procedures: please be sure to discuss this alternative with us as well.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and not a substitute for payments. Some companies pay fixed allowance for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amounts, co-insurance or any other balance not paid for by your insurance company.


We will need to have the following forms listed below filled out and signed before we can commence treatment.  If you’d like to save some time when you come for your initial visit, you can click on the link below, and the forms will open up in a new window, where you can print them, fill them out, then bring them with you.

  1. Patient Information Form
  2. Dental Health History Form
  3. Confidential Medical Health History Form
  4. Consent for Use and Disclosure of Health Information Form
  5. Fees and Payments Form


The following form is for your review only.  If we recommend a specific procedure that you would like to have us accomplish, our office will fill out the appropriate section and ask you to initial and sign this form.

Dental Treatment Consent Form

If you are unable to open the above documents, please download the latest version of Adobe Acrobat Reader here. If you are using the Safari browser and are getting a “file not found error”, open Adobe Reader on your computer, go to Menu: Edit > Preferences > Internet, check the box labeled ‘Display PDF in browser’, and press (OK).