For your convenience: New patient forms & financial policies for your review.

For your convenience, Promenade Dentistry offers two convenient ways to submit your new patient packet to one of our offices. Click on the link below, complete the forms, then:
1) Submit the form securely online to info@promenadedentistry.com or
2) Print the form and mail it, fax it 661-222-2236, or bring it to your next appointment.

Download Patient Information Document. (PDF)

Insurance and Financial Information
The Promenade Dentistry staff would like you to know that we’re committed to providing you with the best care possible. In order to achieve this goal, we need your assistance and understanding of our financial policy in the following areas:

Initial Visit/Consultation
If You Have Dental Insurance: As a courtesy, we will bill your insurance company for your visit to our General Dentistry and Cosmetic Dentistry practice, provided you furnish our office with a completed insurance claim form or insurance card. You may be responsible for a deductible and the percentage that your company requires at this visit.

If you are having future treatment, we would appreciate you paying this bill in full and applying your payment toward the estimated portion of your future visits.

If You Don’t Have Dental Insurance: It’s customary for you to pay our office in full at the time the appointment is made.

Types of Payments Accepted: Promenade Dentistry accepts cash, checks, Visa, MasterCard, Discovery and American Express. It is customer for you to pay for services when you make your appointment.

We do offer various payment plans, and if you wish, our front office concierge will discuss them with you. We realize that, from time to time, temporary financial setbacks may affect timely payments on your account. If such problems do arise, we encourage you to contact our office for assistance to manage your account.

Covered Benefits In Insurance Policies: Our practice is committed to quality care for our patients and we charge what is usual and customary for our area. Please also realize that not all services are a covered benefit in all insurance policies. Your insurance is a contract between you, your employer, and the insurance company’s determination of usual and customary fees.

We require payment of your estimated portion of treatment when it is performed, unless other financial arrangements have been made. Should a problem arise regarding payment from your insurance carrier, you will be notified and a portion or payment is required within 30 days.

Refunds Or Overpayments: We issue monthly or by special request.

Interest Charges/Accounts Referred To Collections: Accounts not settled in 90 days are subject to a 1.5% interest charge on any unpaid balance, which computes to an annual rate of eighteen percent (18%). In the event your account is referred to collection, an additional charge of $25.00 will be added to your outstanding balance.

Workman’s Comp or Accident: This must be approved before the patient may receive services or the patient pays in full.

Cancellation of Appointments: We require at least 48 hours’ notice of cancellation for scheduled appointments. Short notice or failed appointments may result in charges since we are budgeted for the time allotted. Patients that are late may have to be rescheduled as we try very hard to be on time for our other scheduled appointments with Dr. Shawn Javid and Dr. Ben Javid.

Our staff is here to assist you to achieve the treatment you desire and deserve. They will gladly discuss your proposed treatment and answer your questions regarding services, payments and insurance. Again, please do not hesitate to ask for assistance in any of the areas above.