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Welcome to Cortez Family Dentistry
Welcome to our dental family at Cortez Family Dentistry. Every day, the staff strives to provide the highest level of care for you and each of our patients.
We are accepting new patients at Cortez Family Dentistry. We welcome you to the practice and our dental family. Please call the office at 970-565-7275 to set up an appointment for a cleaning, exams and x-ray.
Meet our professional and friendly team. When you first arrive, you will be greeted by Simone, Mary or Renea at the reception desk. They will greet you with a smile and make you feel welcome. If you’re here for a cleaning and exam you will be met with one of our hygienists, Kenzie, Sierra, or Tris who will provide a thorough cleaning and explain proper home care.
Once the cleaning is complete, the doctor and staff will discuss long term options and make plans for your specific dental needs.
Welcome to Cortez Family Dentistry. We hope you feel like you are a part of our family during your visit.
Hours:
Monday – Thursday 8:00 am – 5:00 pm
Fridays are added as needed.
Sincerely,
Dr. Ned Walker D.D.S.
Cortez Family Dentistry Financial Policy
We appreciate the opportunity to serve you. We have found that having a clear understanding of our financial policy may help to relieve some of the anxiety associated with dental visits. This agreement is to inform you of your financial obligation to our practice. We are committed to providing you with the most comprehensive dental care using only the highest quality materials and technology available in the market today. All charges you incur for any treatment that is provided are your responsibility regardless of your insurance coverage. We will always recommend treatment based upon your dental needs, not based on insurance coverage, which can be inadequate with some dental plans. Dental insurance is a benefit used to assist you, not to dictate necessary treatment.
Dental Insurance
We accept all dental insurance and are a preferred provider for many companies. We will be happy to file your dental insurance claim as a courtesy to you. However, your estimated portion is just that, an ESTIMATE. If there is any remaining balance after we receive payment from your insurance company, that balance will be due within 30 days of notification.
Payment Options
Payment is due at time of service. We accept cash, check, Care Credit, Visa, Mastercard, and Discover. Debit cards displaying the Visa, Mastercard logo are also accepted. You may also use your flexible spending account through your employer, as long as they have provided you with a debit card. If we need to make payments over a period of time we have interest free options available upon approved credit. We are not a Medicaid participator.
If you have an issue with your payment, cannot pay in full at this time, please communicate with us to work out the issue and avoid going through the collection process. We charge $30 for returned checks. Failure to pay your account balance will result in your account being turned over to a collection agency. At such time, additional processing fees may be added and this action will adversely affect your credit rating. We would like to prevent using this measure and only plan to use it as a last resort.
As a courtesy if you don't have insurance, we offer a discount of 5% for patients who pay in full at the time of service with check or cash for procedures more than $350. Visa, Mastercard, or Discover for procedures more than $350 may receive a discount of 2.5% at the time of service.
If you have any questions, please ask and we will do our best to answer them for you.
Cortez Family Dentistry Appointment Policy
We value your time and always try to serve you in a timely manner. We ask that you extend the same courtesy in return. We understand that unplanned issues may come up and you may need to reschedule an appointment. Should you need to change a scheduled appointment, we respectfully ask that you contact us at with as much notice as possible or at least 24 hours in advance. Due to the large amount of time involved in treatment, other patients who may wish to take advantage of your appointment time require at least 24 hour notice to accommodate their schedule.
If you are over 15 minutes late for your scheduled appointment it may be necessary to change your appointment. Patients who are habitually late or miss appointments will be placed on the tributary list. When an appointment becomes available, they will be called and given the opportunity to have the appointment. They will not be placed on the schedule in advance.
Thank you for being a valued patient and for your understanding and cooperation with this policy. This policy enables us to open otherwise unused appointments to better serve the needs of all patients. If you have any questions, please ask and we will do our best to answer them for you.
Please understand the appointment policy as stated. Understand that you are responsible for your dental cost regardless of any insurance coverage. The patient also agrees to notify the office within 24 hours to change a scheduled appointment.
I consent to be a patient at Cortez Family Dentistry and agree to a radiographic and clinical examination. I also understand and consent to the following:
During the course of treatment, I may undergo procedures in all phases of dentistry including periodontics (gum treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges, and dentures), implant dentistry, restorative dentistry, temporomandibular disorder treatment, sleep apnea treatment, oral pathology, pediatric dentistry, and radiography.
I have provided a thorough and complete medical history, supply a full list of my medications with dosages, and consent to my dentist communicating with my other medical practitioners to inquire about any aspect of my health history.
No guarantees can be made about treatment outcomes, restoration longevity, or prognoses. I understand that any branch of medicine, including dentistry, can involve unanticipated results.
I will pay in full any cost of treatment or insurance co-payments according to the office financial policy. I understand that even if an insurance pre-estimate is given or a procedure has been pre-approved, I am responsible for any costs that my insurance does not cover. I understand that payment is due at the time of service, including my estimated portion.
I hereby assign all dental benefits to which I am entitled. I hereby authorize and direct my insurance carriers to issue payment checks directly to Cortez Family Dentistry for dental services rendered to myself and/or my dependents regardless of my insurance benefits, if any. Cortez Family Dentistry will provide an estimate of insurance coverage upon request. I understand that Cortez Family Dentistry is not responsible for inaccurate estimates. Payments of a dental claim is not guaranteed by any insurance and is based on eligibility and policy coverage at the time a claim is submitted.
I hereby authorize Cortez Family Dentistry to furnish and/or release any information necessary to insurance carriers and referral dentists concerning my dental treatment or my dependent's dental treatment, to process my insurance claim acquired in the course of my examination or treatment or for my dependent, to allow a photocopy of my signature to be used to process my insurance claims. This order will remain in effect until revoked by me in writing.
My treatment plan may change at any time and I will do my best to approach my dental care with optimism and open communication with my dentist, hygienist, and dental office staff.
My time is valued and Cortez Family Dentistry will always try to serve you in a timely manner. Cortez Family Dentistry understands that issues come up and I may need to reschedule an appointment. Should I need to change a scheduled appointment, Cortez Family Dentistry respectfully asks that I contact the office with as much notice as possible or at least 24 hours in advance.
I am welcome to ask questions about any aspects of my dental care and will request information if I am confused or need more information. I am responsible for clarifying any aspects of my treatment that I am unsure about.
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Signature of Patient or Parent/Guardian Date
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Print Name of Patient or Parent/Guardian
Personal Information and Health History
Patient Name: ______Date:_____/_____/______
Title: __Mr. __Mrs. __ Ms. Gender: __M __F Family Status: __Married __Single __Divorced__ Widowed__Child
Birthdate: ______/______/______Social Security Number: ______-______-______
Address:______City:______State:_____ Zip:______
Phone H:(______) ______-______W:(______)______-______M:(______) ______-______
Email Address: ______
Spouse or Parent Name (for minors):______Responsible Party for Billing Purposes: ______
Emergency Contact: ______Phone: ______
Dental Insurance Information
Name of Insured: ______Insured Patient’s Birthdate: ______/______/______
Insurance Plan Name: ______Employer or Self Plan: ______
Please submit your card information to the front desk for more information.
As per our financial policy – As a patient, you understand that your dental insurance is a contract between you and your insurance carrier. You are responsible for all dental fees. Any dental treatment that is not covered by your insurance coverage is your responsibility.
Dental History:
Do your gums bleed while: Brushing ______Yes ______No
Flossing ______Yes ______No
Are your teeth sensitive: Hot or cold liquids? ______Yes ______No
Sour or Sweet? ______Yes ______No
Do you feel pain in any of your teeth? ______Yes ______No
Do you have lumps or sores in your mouth? ______Yes ______No
Have you ever had a neck, head or jaw injury? ______Yes ______No
Do you experience frequent headaches? ______Yes ______No
Have you ever experienced difficult extractions? ______Yes ______No
Any prolonged bleeding after extractions? ______Yes ______No
Have you had orthodontic care (braces)? ______Yes ______No
Have you ever had instructions on taking care of your gums? ______Yes ______No
Have you been instructed on the correct method of brushing? ______Yes ______No
Do you currently or have a history of the following issues with your jaw? (circle all that apply)
Clicking Difficulty opening or closing Difficulty chewing
Clenching or grinding Bite lips or cheeks frequently Pain
Medical History
Physician: ______Phone: ______Last Exam: ______/______/______
Current and past conditions: (circle all that apply)
High Blood Pressure Low Blood Pressure Heart Attack Heart Disease
Pacemaker Heart Murmur Epilepsy/Siezures AIDS or HIV
Leukemia Diabetes Kidney Disease Fainting
STD Rheumatic Fever Swollen Ankles Emphysema
Asthma Fatigue Anemia Tooth Implant
Cancer Arthritis Joint Replacement Ulcers
Hepatitis/Jaundice Thyroid Issues Stomach Issues Hay Fever
Chest Pains Easily Winded Stroke Seasonal Allergies
Tuberculosis Radiation Therapy Glaucoma Recent Weight Loss
Liver Disease Heart Trouble Respiratory Issues Other: ______
Current medications, including non-prescription and vitamins:
______
Are you under medical treatment now? _____Yes _____No
Please explain: ______
______
Have you been hospitalized for surgery or serious illness? _____Yes _____No
Please explain: ______
______
Do you use: (circle all that apply):
Alcohol Tobacco Cocaine Marijuana Meth Recreational Drugs
Have you taken medication for osteoporosis, currently or in the past? _____Yes ______No
Boniva Fosamax Aredia Actonel Other______
Date started:______/______/______Date ended:______/______/______
Do you have any known drug allergies? (circle all that apply)
Local Anesthetics Penicillin Other Antibiotics Sulfa Drugs Barbiturates
Sedatives Iodine Aspirin Other: ______
Women:
Are you pregnant? ____Yes ____ No Are you taking birth control: ____Yes ____ No
Are you nursing? ____Yes ____ No
To the best of my knowledge the above information is complete and correct. I understand it’s my responsibility to inform Cortez Family Dentistry of any health changes for myself or my child/children.
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Signature of Patient or Parent/Guardian Date
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Print Name of Patient or Parent/Guardian