Office Policy

JAI H. SHIN, DDS, PLLC
& Associates (AKA Lux Smiles)

7 Gramercy Park West
New York, NY 10003
+1 (212) 777-7126

This online form is primarily for print only, so you can:

Fill out information online, print out the completed form, and sign it at our office; or
Print out a blank form, fill it out and sign it at our office; or
Fill out the forms that we have in the office and sign there.

1. CANCELLATION POLICY

Our office takes pride in striving to see our patients at their scheduled appointment time. Your appointment time is reserved specifically for you. Therefore, we require a 24 hour notice for a cancelled/missed appointment. Otherwise, a charge will be rendered based on the appointment time alloted.

2. INSURANCE POLICY

Please be advised that dental benefits are not a guarantee of payment. Payment in full, or estimated copays are due on the day of service. Your insurance provider will make the final determination of benefits when they receive the claim.

Our dental office administrative staff is not responsible for tracking your benefits, maximums or frequencies. If you have questions regarding coverage and benefits, please contact your insurance provider for details.

3. COVID-19 POLICY

All visits to our office must be scheduled with a confirmed appointment. To mitigate the potential spread of COVID-19, a face covering made of cloth or mask is required to enter our office. While inside, social distancing and any other COVID-19-related instructions must be observed to keep everyone safe.

Thank you,
Jai H. Shin, DDS, PLLC

4. SIGNATURE

Signature

Date of signature

Printed name

JAI H. SHIN, DDS, PLLC & Associates (AKA Lux Smiles)

OFFICE POLICY

1. CANCELLATION POLICY

2. INSURANCE POLICY

3. COVID-19 POLICY

Thank you, Jai H. Shin, DDS, PLLC

4. SIGNATURE

$250 Dental Cleaning, X-rays & Exam

Normally $500

JAI H. SHIN, DDS, PLLC
& Associates (AKA Lux Smiles)

Thank you,
Jai H. Shin, DDS, PLLC