New Patient Information and Forms

Welcome to Willis Dental. As one of the best Salem Oregon Dentists, we take your oral health very seriously. Before we start your treatment, we will need some brief information on your personal medical history and financial information with our forms below. All information is kept strictly confidential.

Payment options:

Cash, Check, Credit Card-Visa, Master Card, Discover and American Express, Care Credit

Discounts:

5% cash discount- no insurance payment made with check or cash

5% Senior Citizen discount for patients 65 years and older

Insurance Network Participation:

Delta Dental / MODA- Premier, Preferred and Exclusive

MetLife

LifeMap

Regence Blue Cross Blue Shield

Cigna-PPO

Ameritas

Assurant

LifeWise

Standard

United Concordia

Aetna

Guardian

DenteMax Network

As a courtesy, please call with your insurance information and we will check your benefits prior to your appointment.

Please note that you are responsible for the fees charged by our office, no matter what your insurance coverage may be. As a courtesy to you we will bill your insurance company and track claims.  If financial arrangements are needed it must be discussed with the Accounts Manager prior to your treatment. 

Click The Button Below To Download The Form

Print, complete and bring with you to your appointment. We look forward to seeing you in our office.

New Patient Form
Transfer Dental Records Form
Sleep Assessment Form