New Patient Forms and Insurance/Financing

Below you will find several convenient ways to save time with your health forms prior to your appointment. If you would prefer printing out our form and bringing it into our office, please download the PDF files below, fill them out and bring with you to your appointment. Also, you will find our financial arrangements options below.

View New Patient Form

Loudoun Smile Center - New Patients

Patients Forms


Loudoun Smile Center Health History Page 1

Loudoun Smile Center Health History Page 2

Consent Agreement

Policy Form

Thank you and we look forward to seeing you at your appointment!

Financial Arrangement Options

We understand that each patient’s financial situation is unique. However, we do not believe that budget restrictions should prevent anyone from receiving the care that they need and deserve. This is why we offer a wide variety of payment and financing options. You can enjoy great oral health, and the gorgeous smile of your dreams, without breaking the bank.

Dental treatment, whether it is restorative or cosmetic, is one of the best investments that you can make in yourself. It can improve your health, quality of life, and self-confidence. Therefore, we will assist you with affordable financing, convenient scheduling, and excellent customer service.

We are proud to offer flexible financing through CareCredit, a financing plan provided by GE. You can apply online, by telephone, or in our office. CareCredit offers affordable, interest free, 6, 12 or 18-month payment plans. Our friendly staff will be happy to help you apply if you need assistance.

Please see the CareCredit website for full details.

Loudoun Smile Center - Piggy Bank


Loudoun Smile Center accepts most dental insurance plans. As a courtesy, our efficient office personnel will help you with billing your insurance provider for eligible treatments. We strive to provide an accurate estimate of fees and insurance coverage before beginning treatment. However, due to variances and complexities of insurance contracts, we cannot guarantee when or how much your insurance will pay. Please remember that your account is your financial responsibility. You will owe any portion of the costs that your insurance does not pay.

Complete Health Dentistry in Ashburn

Your oral health is our priority. A healthy mouth is the gateway to a healthy body.

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