New Patient Form

Are you ready to start smiling?

Fill out our online paperwork so we can get you started!

If you prefer, you can also print a blank form and fill it out by hand.

Patient Information
Mailing Address
Contact Information
Other Information
Billing Party

Billing Address
Contact Information
Insurance Information

As a courtesy to our patients, we will be happy to file insurance claims on your behalf. We can provide pre-authorizations if needed and are working to help you maximize your insurance benefits. To have claims processed in a timely manner we do need a copy of your dental insurance card, and the following infomation filled out completely.

Medical Information

Check the box if you have, or if you ever had, any of the following

Medical Issues
Women Only
Medication and Supplements
Dental Information

Check the box if you have, or if you ever had, any of the following

Dental Issues

Our Philosophy

Keep it simple and straightforward. Our treatment fees are based on the amount of time the treatment takes. The less complicated the treatment is, the less time it will take, and the less is will cost. We won't try to upsell you to a longer treatment. Shorter treatment times are better for everyone. Patients don't want to be in braces forever, and less time in braces means a lower risk of plaque buildup damaging tooth enamel. Our goal is to deliver the very best and highest quality results in the shortest amount of time.

How Much Will it Cost?

We have a range of fees based on treatment time. The average cost for comprehensive treatment at Jolley Orthodontics in 2016 was $4503.62. The average treatment time for our patients in 2016 was 12.2 months. This is much lower than the national average. An official survey conducted by the American Dental Association revealed that in 2016, the average cost for comprehensive treatment for adolescents was $5687.27, and for adults was $5977.73. Our average is more than $1000 less.

Early treatment (for kids around ages 7-9) usually isn't necessary, When it is, the cost is much less than comprehensive treatment.

Insurance, Down Payments, Discounts

We accept dental insurance. Most dental insurance providers will pay a one-time orthodontic benefit, ranging from $1000 - $2000. A simple $250 down payment is necessary to get started. A large down payment can reduce your monthly payments, but it's optional. The rest is broken up into affordable monthly payments at 0% interest, and can be financed for any length of time, up to 2 years. You'll receive a 5% discount if you pay in full.

Putting it All Together

Of course, your individual plan may vary, but as an example, let's crunch the numbers above.

Total Fee $4500
Insurance Benefit-$1500
Down Payment -$250
Remaining Balance $2750

12 monthly payments at 0% interest = 229.16 per month
24 monthly payments at 0% interest = $114.58 per month

Let's Get Started!

Initial consultations are free. During your exam, we'll provide all the information that you need and will be glad to answer any questions. The benefit of a healthy and beautiful smile is worth the investment for you or your child. Call 435-781-1234 to schedule your free exam.