(Fill it out on your computer and print, or print it to fill out by hand.)
Online Patient Form
(Fill it out on the website and print, or submit it electronically to our office.)
Download Patient Form
Here are some helpful links:
Snap On Smile
To make your next visit with Dr. L. C. Chilimigras as pleasant as possible, we invite you to fill out the following patient forms. Either fill out the form online or print out your form and bring it completed to your appointment.
We are a preferred provider for both Delta Dental and Blue Cross Blue Shield. We also file all insurance claims as a courtesy to our patients. We accept payment in the form of cash, check, debit, Visa, MasterCard, and Discover.
We invite patients who don’t currently have dental insurance to apply for CareCredit, a third-party no-interest monthly payment plan that allows you to get the treatment you need at a price you can afford. For more information regarding CareCredit or your payment options, please contact our office. Our wonderful staff will be happy to answer all of your questions.