3520 St. Johns Ave.
Palatka, FL 32177

459 W. Call St.
Starke, FL 32091

Chapman Orthodontics Palatka, FL 32177
386-328-8351

Chapman Orthodontics Starke, FL 32091
386-328-8351

Patient Name:

Patient Forms

Appointments

Your scheduled appointment time has been reserved specifically for you. We request 24-hours notice if you need to cancel your appointment. We are aware that unforeseen events sometimes require missing an appointment, and we appreciate your cooperation.

Payments

It is our mission to provide you with affordable, high-quality treatment that fits your budget! We offer a variety of payment options to meet your needs. For your convenience, we accept Visa, MasterCard and Discover. We offer a discount for payment in full and financing through Capital One Healthcare Finance.

Insurance

If your insurance covers orthodontic treatment, you will receive the benefit of reduced personal costs. Many insurance policies have a lifetime orthodontic benefit that is distinct from regular dental insurance. Remember that insurance policies vary, and we will review your insurance to determine the appropriate course of action.

Once treatment has started, we will file your claims. To help us with your insurance filing, please complete the insurance questions on our questionnaire. Please remember that orthodontic insurance is a benefit for you or your child. If, during the course of treatment, your benefits change, the financially responsible party is accountable for all charges.

You may access the following forms to assist us with your care. Please print and fill out the appropriate form, then bring it to your appointment.

Skip to content