Patient Information and Forms

What you Need to Bring to your First Appointment

  • Insurance Cards (both medical and dental)
  • Drivers License or other Photo ID
  • List of Medications
  • If you were referred by a dentist of medical doctor, bring any referral forms or X-rays


You may preregister with our office by filling out our secure online Patient Registration Form. After you have completed the form, please press the "Complete and Send" button at the bottom to send us your information. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

Privacy Notices for Lowell, Nashua and Chelmsford Oral Surgery

You will be asked to sign a Privacy Notice when you come to the office. If you would like to review our privacy policies, or print out a copy from home, you can access it here.


Non-Discrimination Notice

Surgical instructions

Below are copies of our pre- and post-operative instructions, which will be explained to you when you come to the office. We have also provided dietary guidelines to ensure you know what foods to eat during your recovery.

Pre Operative Instructions for Patients

Post Operative Patient Instructions and Dietary Guidelines


We are in network with most medical and dental insurance companies.  If you do not see your insurance on the list; please call and ask one of our associates.

Medical Insurance

  • Aetna
  • Blue Cross Blue Shield of Massachusetts
  • Blue Cross Blue Shield (Federal)
  • Champus
  • Cigna
  • Fallon
  • GIC Indemnity
  • Harvard Pilgrim Health Care
  • MassHealth
  • Medicare
  • NH Medicaid
  • Tricare
  • Tufts
  • Unicare
  • United Healthcare (UHC)

Dental Insurance

  • Aetna
  • Altus Dental
  • Assurant (DHA & Sunlife)
  • Basix Dental Savings (College Students)
  • Cigna
  • Delta Delta of MA (all products)
  • Dental Blue
  • Dental Benefits Providers
  • Fallon
  • GEHA-  Dental Connection
  • GRID Dental Network
  • Guardian
  • Liberty Dental
  • Lincoln Dental Connect
  • MassHealth
  • NE Delta Dental
  • NH Medicaid
  • Principal
  • Tricare
  • UCCI (Dental Network of America (DNoA))
  • United Healthcare (UHC)

Our Financial Policy

It is our goal to provide you with the finest quality care at the most reasonable cost possible.  To accomplish this, we will work with you to maximize your insurance reimbursement for covered procedures and find a payment option that works best for you.  For your convenience, we accept cash, checks, Visa, Discover and MasterCard, American Express as well as Care Credit.

Insurance:  We participate and are “in network” with most insurance plans, including Medicare, NH Medicaid and MassHealth.

Please note that insurance is a contract between you/your employer and the insurance company. You are fully responsible for all fees and charges regardless of your insurance coverage.  It is rare an insurance company covers 100% of services.  We will make every attempt to know your insurance benefits to provide you with an accurate estimate of your out-of-pocket expense before your appointment.  You will be financially responsible for estimated co-insurance, deductible, co-pay or non-covered services at the time of service.

As a courtesy, we will file your insurance claims for you.  You may have benefits for your surgery through your medical and/or dental insurance, or no coverage at all. Because of this, we ask you to call your insurance company prior to surgery to verify your benefits (i.e. deductibles, limitations, exclusions and yearly maximums).

No Insurance:  If you do not have insurance, we require payment in full at the time of service. We give a 5% discount for surgeries/procedures, when paying with cash or check, in advance (defined as at least one day before your surgery/procedure).

Office Visits & Consultations:  Our surgeons perform an office visit/consultation prior to your treatment.  If you do not have insurance, we require payment in full at the time of service.  If you do have insurance, any copayments, deductibles or coinsurance will be due at time of service. 

Surgeries/Procedures:  We will provide you with an out-of pocket estimate when you meet with our treatment coordinator.  If you have insurance, we may submit a predetermination of benefits request to your insurance. 

If you are scheduling dental implants or a large graft procedure, ½ payment is due upon scheduling and ½ due the day of surgeries.

For all other procedures/surgeries all payments, and balances for surgery will be collected before the service is performed. Co-payments, deductibles, and non-covered services are due before treatment.

Cancellation/Rescheduling:  We strive to schedule appointments so we meet the needs of every patient while minimizing your wait time.  We will call you 48-hours before your appointment to remind you of your appointment.  Likewise, we understand circumstances arise which may necessitate you needing to reschedule or cancel your appointment with us.  We request you contact us within 24 hours to reschedule or cancel appointments.  Please be aware that if two or more appointments are cancelled without 24-hour notice, you may be asked to provide a deposit before rescheduling occurs.

Veterans & Senior Citizens 65 years and older:  We are honored to offer a 5% discount to our Veterans and senior citizens.

HMO Patients:  If services provided are considered under your medical insurance, (biopsies, cysts, TMJ, infections, jaw deformities) and you are a member of an HMO, you must have a referral from your primary care physician. A referral from a dentist is not adequate for medical insurance consideration. Obtaining a medical referral is the patient’s responsibility.  If you do not have a referral, your medical insurance company may deny your claim or process it as “out-of-network”.

Workers Compensation:  If our office is providing services to you that are covered by a Workers’ Compensation claim, necessary insurance billing information and employer authorization forms must be provided to our office prior to the performance of services.

Personal Injury:  This office does not accept liens nor bill for auto-accident or other liability or lawsuit-related cases. The patient is responsible for services provided at the time of service.

Minor Patients including those with divorced parents:  The adult accompanying a minor is responsible for the full payment.  The parent who brings the child to the appointment is deemed responsible for payment, regardless of who provides insurance coverage. Our office will not become involved in disputes over which parent is the responsible billing party.

Payment Options

  • Cash, Check, Credit Card (Visa, Mastercard, American Express or Discover)
  • Payment is due at the time of service unless other payment arrangements have been made in advance.
  • We can facilitate financing of your procedure through CareCredit.

Financing Through CareCredit

If you need help with financing, we recommend you set up an account with CareCredit.  This specialized financing can help you pay for treatments and procedures not covered by insurance.  You can secure deferred interest financing or low minimum monthly payment options through this service. Once you set up your CareCredit account, you can use it for other medical needs in your family, including dentistry, Lasik, cosmetic procedures, hearing aids and more.

To learn more, or set up an account, please click below:

Lowell, Nashua & Chelmsford Oral Surgery Associates, complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.  ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you.  Please see our Notice of Non-Discrimination for more information.

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Note of Non-Discrimination