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Our office is currently closed until further notice due to COVID-19. We hope to reopen by May 1, 2020, but this is subject to change.

If you are a patient of record with a dental emergency, please call the office to get the information for our on call dentist.

Thank you, The office of Dr. Susanne Jackson and Dr. Tammy Samuelson

(919) 968-9874

Patient Forms

Please print out the forms below, fill them out prior to your appointment and bring them with you. If you do not bring the forms with you, please prepare to arrive 15 minutes early to complete them in the office. You are also welcome to email your completed forms to us.

Authorization for Release of Information

Authorization for Release of Medical Records

Broken Appointment Policy

Financial and Office Policies

Medical History

New Patient Registration

Notice of Privacy Practices

Patient HIPAA Consent Form

Our Policies

Financial Policy

We ask that all services be paid in full at each appointment. The following payment options are accepted: cash, check, debit card, and credit card (MasterCard, Visa, American Express, and Discover). There is a $35 returned check fee. Accounts outstanding more than 60 days will bear an applicable interest rate.

Insurance Policy

When services are paid in full, we will immediately file your insurance claim electronically. Your insurance company will then reimburse you directly. We do not accept assignment of benefits and are not an in-network provider.

Missed/Broken Appointments

We require notice of at least 24 hours for appointment cancellations. Anything less may result in a $50 broken appointment fee.

Thank you for understanding and respecting our policies. We will be happy to discuss them in further detail.

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