PATIENTS

Request An Estimate

We make every effort to provide you with the finest care and  most convenient financial options. We will call your insurance, on your behalf, to calculate the most accurate estimate. Submit the form below and one of our treatment coordinators will follow up with you within 5-7 business days.

Patient Information
ex. 01-05-1975
Dental Insurance
Does the patient have dental insurance?
Type "N/A" if you do not have dental insurance.
First & Last
Type "N/A" if you do not have dental insurance.
ex. 01-05-1975
Type "N/A" if you do not have dental insurance.
(located on your dental insurance card)
Type "N/A" if you do not have dental insurance.
Do you have a secondary dental insurance?
If yes, we will contact you for additional information.
Medical Insurance
Type "N/A" if you do not have medical insurance.
First & Last
Type "N/A" if you do not have medical insurance.
ex. 01-05-1975
Type "N/A" if you do not have medical insurance.
(located on your dental insurance card)
Type "N/A" if you do not have medical insurance.
Do you have a secondary medical insurance?
If yes, we will contact you for additional information.
Reason For Visit
What do you need to be seen for?
Check all that apply.
If having a tooth extracted, would you like to be sent information on replacing the tooth with a dental implant?
Are you interested in IV Sedation?
**IV sedation is recommended by our doctors. It is also the most popular option for patients as it helps reduce pre-procedure anxiety. Patients who chose IV sedation did not feel pain or remember anything from their procedure including tastes, smells, and sounds.

Visit our IV sedation page for more information.
**We may contact your dentist to request your xrays in order to create the most accurate estimate.
Preferred method of contact:
ex. 555-555-5555

If needed, we may contact you for more details to create the most accurate estimate possible.

© 2017 Nebraska Oral & Facial Surgery