A credit card on file is required for booking of appointments with Dallas Functional Dentistry.  

For new patient online and other bookings, your requested appointment cannot be confirmed until we physically speak with you and obtain required information.  New patient forms require completion no more than 48 hours after booking the appointment, or the appointment may be subject to automatic cancellation.  Please call the office after booking online at:  214-363-4414, and one of our smiling team members will be happy to assist you with an appointment booking and confirmation. 

*Because of HIPAA Federal regulations protecting your privacy, we wish to inform you that we will release no information about you without your consent. We are allowed to release this information to your insurance company or as necessary to get paid for our services. You can have access to your records by simply asking.

By agreeing with this consent form, you permit the release of any information to or from your dental practitioner as may be required.

You understand that you are financially responsible for all charges whether or not paid by insurance. You authorize the use of your signature on all insurance submissions. Your dental practitioner may use your health care information and may disclose such information to your Insurance Company(ies) and their agents for the purpose of obtaining payment for service and determining insurance benefits or the benefits payable for related services.