Patient Forms

Written Financial Policy

Time-Saving Patient Forms

Save time by completing these new-patient forms and bringing them with you to your first appointment. Print out the forms below and fill them out before your first visit.

Questions? Call us at 919-453-0777 or e-mail us today.

Dental Health History Form
Insurance Form
Financial Policy
Consent for Use and Disclosure of Health Information
These forms require the free Adobe Reader application, which is already installed on most computers. If you do not have Adobe Reader, click here to download it for free. Mac Users: you can also open PDF’s using the built-in “Preview” application.

Appointments

Your scheduled appointment time has been reserved specifically for you. We are aware that unforeseen events may require missing an appointment. If you do not reach out to our office within 24 hours in advance, you are subject to being charged an additional fee.

Insurance Policy & Payment Options

We are happy to file your insurance and help maximize your benefits. Because policies vary, we can only estimate your coverage due to the complexities of insurance contracts. Your patient estimation must be paid at the time of services. Insurance companies allow 30 days to render payment. If you have any questions please give our office a call so we can answer any questions or concerns you may have.At Wake Cross Roads Dentistry we offer a variety of payments via cash, Visa, MasterCard, checks and we also offer care credit with a 12 month no interest with any 500.00 or more.

Book An Appointment 

Call

919-453-0777

Address

4008 Mitchell Mill Road,
Suite 108, Raleigh NC 27616

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Office Hours

MONDAY: 8 AM to 5 PM
TUESDAY:1PM to 7 PM
WEDNESDAY:1PM to 7 PM
THURSDAY:8AM to 2 PM
FRIDAY: CLOSED
SATURDAY (every 3rd of the month): 8 AM to 4 PM
SUNDAY: CLOSED

CLICK HERE FOR COVID-19 & OFFICE UPDATE

To Our Most Valued Patients:

We will be closed and reopening March 1st at 1pm. We must implement new restrictions on patient care. This is based on the latest advice we have received from the Centers for Disease Control, the NC Dental Board and the American Dental Association.

If you have an appointment  for non-emergency dental treatment (such as a checkup or cleaning or fillings), the appointment has been canceled, and we will work with you to reschedule. We are now restricting treatment to urgent or emergency care only.

This decision was not easy, but necessary. The health and well-being of our patients and team members are our primary focus.

We regret that we must restrict our patient care this way. We are serving our patients in the safest manner possible by following the advice of the U.S. Centers for Disease Control and Prevention under these difficult circumstances. In doing this, we will safeguard the health and safety of our patients, our team members, and the entire community. Thank you all for your cooperation and understanding during these trying times and we wish you all the best of health.

In Good Health,
Dr. Dillard and Team @ Wake Crossroads Dentistry