HOW DOES IT WORK?

✅Choose The Price You Want To Pay.

✅CHECKOUT.

✅CONFIRM YOUR APPOINTMENT.

✅SEE DENTIST.

Please Read

You can not cancel your appointment, only reschedule 24 hours before. If you cancel your appointment, you will forfeit the special and will pay regular price If you decide to book again.

MAKE A QUICK APPOINTMENT

Name Your Price Form

Step 1 of 3

33%

Status(Required)

New Patient

Current Patient

Do You Have Insurance?(Required)

Yes

NO

Want To Try Our Name Your Price Special !(Required)

YES

NO

Pay What You Can On Your First Check Up Which Includes Exam & X-ray

How Much You Want To Pay?(Required)

Please enter a number greater than or equal to 15.

What Insurance Do You Have?

Amerita PPOAetna PPOBlue Cross PPOCigna PPODelta Denta PPODenti-CalFirst Dental Health PPOGold CoastGuardianHumana PPOMedi-CalMetlife PPOPrincipal PPOUnited ConcordiaUnited Health PPOOTHER PPO INSURANCE

Is This An Emergency?(Required)

Yes

No

What's Your Nearest office(Required)

Newbury Park/Thousand OaksOxnardPort HuenemeSanta PaulaVentura

Date You Want To Come?(Required)

MM slash DD slash YYYY

Time You Want To Come?(Required)

Hours

:

Minutes

AM PM AM/PM

Name(Required)

First Last

Date Of Birth(Required)

MM slash DD slash YYYY

Email(Required)

Phone(Required)

Reason For Your Visit

Welcome To The Name Your Price New Patient Special

New Patient Dental Exam & X-ray(Required)

Price: $0.00

This is how much you would be paying for your first Dental Exam & X-ray

When Would You Like To Pay?(Required)

Now

At The Office

Payment Method

PayPal CheckoutCredit Card

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number Expiration Date   Security Code Cardholder Name

Total

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