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Duxbury Children's Dentistry

781-934-7111

(781) 934-7111

  • Home
  • Our Office
  • Services
  • New Patients
  • Record Release
  • Forms & Policies
  • Health
  • More
    • Home
    • Our Office
    • Services
    • New Patients
    • Record Release
    • Forms & Policies
    • Health

(781) 934-7111

Duxbury Children's Dentistry

781-934-7111
  • Home
  • Our Office
  • Services
  • New Patients
  • Record Release
  • Forms & Policies
  • Health

Forms & Policies

Patient Forms

All patient forms can be requested from our office as an online form and completed securely via your mobile device. Call or message us to request the online forms.

If you choose to use paper, simply print & complete the forms below.

New Patient Packet (pdf)

Download

Authorization for Release of Dental Records (pdf)

Download

Notice of Privacy Practices-HIPAA (pdf)

Download

OVER 18 years old Medical History Packet (pdf)

Download

Medical History UPDATE: established patients only (pdf)

Download

Guardian Authorization Form (Consent to Treatment Without a Parent/Legal Guardian Present) (pdf)

Download

Nitrous Oxide (laughing gas) Consent Form (pdf)

Download

Tooth Extraction Consent Form (pdf)

Download

Silver Diamine Fluoride (SDF) Consent Form (pdf)

Download

Abscess & Cellulitis Information for Parents (pdf)

Download

Informed Refusal of Xrays (pdf)

Download

Filling Information for Parents (pdf)

Download

Insurance

In-Network Insurance Plans:

Out-of-Network Insurance Plans:

Out-of-Network Insurance Plans:

Altus

Ameriplan

Ameritas

Assurant

BCBS/Freedom Blue/FEP

Cigna

Delta Dental Premier

Guardian

Harvard Pilgrim (not pediatric)

Principal

Out-of-Network Insurance Plans:

Out-of-Network Insurance Plans:

Out-of-Network Insurance Plans:

Aetna

Delta Dental PPO
Dentemax

Harvard Pilgrim Pediatric

Metlife

Total Choice

Tricare

United Health Care

United Condordia

We Do Not Accept:

Out-of-Network Insurance Plans:

We Do Not Accept:

Aetna DMO

Cigna DMO

Delta Care

Delta Dental EPO

Delta Dental Health Connector

Delta Plans Associated with MassHealth: MassHealth, Unicare, Children's Health Network

Fallon

Health Net

Neighborhood Health

Tufts Health Connector

Tufts

Financial Policies

If you have a different dental insurance policy, you will be responsible for paying for services, and we can provide you the necessary forms to submit to your insurance company. If you do not have dental insurance, you will be responsible for all procedure costs due at each visit. 


The primary goal of Duxbury Children's Dentistry is to provide quality dental care for your child. Inherent in our relationship with your child is a financial relationship with you as the child's parent/guardian.


  1. Payment in full is due at the time services are rendered. We encourage patients to use credit cards, however we do not want financial concerns to interfere with important care for your children. We accept cash, personal checks, MasterCard and Visa. In some instances, you may arrange for a payment plan with our office. Late fees per month may apply. Payment plans must be paid off within six months. Please speak to our staff if this is something you with to arrange.
  2. Your insurance benefits are determined by the type of plan chosen by you and/or your employer. Duxbury Children's Dentistry has no say in the selection or determination of your insurance benefits, terms of your Policy, determination of your benefits, or method of reimbursement. Our office will make every attempt to assist you with understanding your benefits, however, it is ultimately your responsibility to be knowledgeable about your Plan as well as the deductibles, maximum allowances, and other provisions within said Plan. Duxbury Children's Dentistry will submit claims to your insurance company in a timely manner and will submit pre-treatment estimates to your insurance company. Should you choose to complete your child's care without receiving an estimate from your insurance company it is your responsibility to contact your carrier with any questions. We reserve the right to collect an estimation of what we feel will be due and will refund or credit you any money that was overestimated and reserve the right to bill for what was not collected on the day of service. If you are concerned about your co-pays it is wise to make appointments for all non-urgent care at least three weeks after your cleaning in order to allow processing time of the estimates.
  3. Duxbury Children's Dentistry's standard for filling teeth is a tooth-colored resin. If your child is having a filling in the back molars, insurance companies will often reimburse only at the amalgam (silver) filling rate. Your co-pay may be higher if you opt for tooth-colored fillings. The dentist is happy to discuss the pros and cons of both with you. To help determine what will be covered by your insurance provider, we can send a pre-treatment estimate out.
  4. Please be aware that appointment times are important not only to the efficient operation of our practice but also to our patients. Broken appointments are subject to a fee up to $80.00. 

  • Contact Us

Duxbury Children's Dentistry

95 Tremont Street-Suite 18, Duxbury, MA 02332

Tel. 781-934-7111 Fax. 781-934-7125

info@duxburychildrensdentistry.com

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