Call or Text: 269-429-2511 2800 Niles Road, Saint Joseph, MI 49085
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New Patient Intake Form

Hello! We heard you're looking for a new dentist, and we are thrilled to hear that you are interested in Smiles on Niles. Hopefully this means that you've heard wonderful things about us!

Our office is currently experiencing a large influx of new patients, and because we already have a large population of existing patients, we need to collect some vital information to determine if we can meet your dental needs. This includes referrals, insurance information and scheduling needs.

Fill out the form below and it will be sent straight to our team. Prefer paper? You can still download the printable PDF and mail, email, or fax it to us, or drop it off at our office.

Your Information

Used for insurance filing. If you prefer, leave this blank and provide it by phone.

Dental Insurance

Please attach a photo or scan of your DENTAL (not medical) insurance card. A phone photo is fine.

For example, if the insurance is through a spouse's or parent's employer.

How did you hear about us? *
Scheduling

We may not always be able to accommodate your requests, but we certainly do our best!

Your Dental Needs

New patient intake forms are evaluated one time per month. At that time, a patient coordinator will contact you via email or phone. If any of the above information is omitted, you will automatically be denied.

Smiles on Niles is not in-network with any insurance companies. However, we will courtesy file your insurance for you! This means that you'll pay in full at the time of your service and the insurance company will reimburse you directly, usually within 1-2 weeks, depending on the company and the claim.

Please note that we are currently booking 4 to 6 months out for new patients. That can change quickly depending on the flexibility of your schedule and changes in ours.

First appointment: the first appointment for new patients is only offered on select Thursdays at 3 p.m. and is scheduled for 1.5 to 2 hours, depending on the patient's needs. This ensures the doctor has ample time set aside for new patients. No exceptions can be made to this time frame on the first appointment.

Your form is sent directly and privately to our patient coordination team. We look forward to having you as part of our dental family!

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