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Town Creek Family Dentistry

(865) 816-6327
  • TEAM
  • SERVICES
  • CONTACT
  • TESTIMONIALS
  • NEW PATIENTS
  • MEMBERSHIP
(865) 816-6327
  • TEAM
  • SERVICES
  • CONTACT
  • TESTIMONIALS
  • NEW PATIENTS
  • MEMBERSHIP
  • Patient Information

    Check all that apply
  • Medical History

    (check all boxes that apply)
  • (including nonprescription drugs)
  • Please include the year, and the reason.
    Example: 2008 - Heart Surgery
  • (Fosamax or Actonel for osteoporosis, chemotherapy, etc.)
  • NOTE: Antibiotics (such as penicillin) may alter the effect of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.
  • Dental History Information

  • Please enter a number from 1 to 10.
  • Responsible Party

  • Dental Insurance Information

  • front of card
  • back of card
  • First and Last Name
  • Secondary Dental Insurance Information

  • Signature


    I certify that I have read and understand the questions above. I acknowledge that the questions have been answered to my satisfaction. I will not hold my Dentist or any other members of his/her staff responsible for any errors that I have made in the completion of this form.
  • New Patient Form Completion Signature
  • Financial Policy and Agreement

  • Diagnostic & Consultation Services


    All Fees are due at the completion of your diagnostic appointment (today). If you have questions about the amount due today, please ask the receptionist. A treatment plan will be created with estimated costs shown for any future appointments.
  • Insurance Payments


    If you have insurance coverage, we will file the necessary paperwork with your insurance carrier, based on the information you provide for us. We will credit your account with the insurance payment amount when it is received. This is a courtesy offered to our patients, we accept no responsibility or liability due to denied claims, exceeded maximums, or denials due to insurance plan/policy limitations or plan/policy guidelines. You are fully responsible for knowing your own insurance coverage limitations and are liable for any charges incurred because of services rendered regardless of how your insurance pays. You are responsible for knowing what your out of pocket portion will be at the time of treatment. All coverages, co-pays, deductibles and/or amounts due are estimates only.
  • General Payment Terms


    100% of the fee is due at the time of service if the overall treatment cost is $500 or less. If the fee is more than $500 then payment arrangements may be made, please speak to our Financial coordinator for your payment options.
    We accept Checks, Cash, and all major credit cards. Payment plans are available through Care Credit or Compassionate Finance upon approval.
    Our office does offer 5% discounts for NON-insured Students, Seniors, and those making cash payments at the time of service. A 3% discount is also offered for those paying in full with a credit card. Discounts are not cumulative.Maximum allowable discount is 5%.
  • Scheduling and Cancellation Policy


    Town creek Family Dentistry is dedicated to your quality care and is pleased to reserve your appointment time exclusively for you. We attempt to schedule appointments that are most convenient for you and that fit your personal schedule. We respect our patients time and make every effort to remain on schedule. We understand delays can happen. However, if you know you’ll be more than 10 minutes late, we may have to reschedule. Some visits are more complicated than initially anticipated, and emergencies may arise that could possible delay us. In such a case, every effort will be made to notify you beforehand. Because we reserve time exclusively for each patient, we ask that you make every effort to not change your reserved dental appointment. If you find that you cannot keep your scheduled appointment, we require a minimum 48 hours notification. Last minute cancellations and no shows will be charged a $25 fee that is not covered by insurance and is non refundable. To notify us of any change 48 hours prior, please call our office, leave a voicemail, text or email. If you break two appointments, we will require a 20% deposit to schedule your next appointment. If you break a third appointment you may be dismissed from the practice
  • Signature


    I certify that I have read and understand the above information to the best of my knowledge. I authorize and request my insurance company to pay directly to Town Creek Family Dentistry. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my or my dependents behalf. In the event, that I default on my account(s), I agree to pay collection costs, attorney fees and/or any fees incurred in the attempts of TCFD and its affiliates, to collect this debt or any future debts.
  • Financial Policy Agreement Signature
  • Notice of Privacy Practices Acknowledgement


    I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information.

    I understand that this information can and will be used to:
    • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
    • Obtain payment from third-party payers.
    • Conduct normal healthcare operations such as quality assessments and physician assessments.
    I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
  • Signature

  • Privacy Practices Acknowledgment Signature
  • Consent For Dental Photography


  • At Town Creek Family Dentistry we may take photographs and/or videos of your face, jaws, mouth, and/or teeth before, during, and after treatment. These photographs are used for planning and education and better communication with laboratories and specialists. Photos that depict items of interest, unique findings, or successful outcomes may be of benefit to the dental profession and may be of great value in lectures, seminars, demonstrations, professional publications and/or study clubs. These photos may also be useful for marketing and social media.

  • I further understand that if the photographs and/or videos are used, I will not be compensated, financial or otherwise, for the use of these photographs.
  • Signature

  • Consent for Dental Photography Signature

NAVIGATE THE SITE

  • TEAM
  • SERVICES
  • CONTACT
  • TESTIMONIALS
  • NEW PATIENTS
  • MEMBERSHIP

CONVENIENT LOCATION

Town Creek Family Dentistry
875 Hwy 321 N.
Lenoir City, TN 37771

(865) 816-6327

We want you to enjoy your visit

Town Creek Family Dentistry is a small town family practice committed to making you comfortable. We are not in a hurry. We will take our time with you and all our patients to ensure that you are getting the right care and that you are comfortable. Schedule an appointment today. We look forward to serving you!
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