PATIENT FORMS

Going to the dentist can be an overwhelming experience, especially on your first dental visit. Let us put your concerns and anxieties to rest. Our goal at Vayner Family Dentistry is to make every patient experience as comfortable as possible.

To make your visit as pleasant and brief as possible, there are a few things you should bring with you. Please bring your dental x-rays from the last six months to your first appointment.

With just a few simple forms, we’ll ask for relevant medical history, any medications you might be taking, your dental history, and any dental insurance coverage you may have.

Want to get a head start? Download or fill in the new-patient forms below.

These documents are also in Adobe PDF format. If you’re unable to read PDF files, please download free Adobe Acrobat Reader here.

Notice of Privacy Practices

Online Intake Form

Patient Insurance Form

Intake Form (PDF)

Patient Insurance Form (PDF)

First Name(Required)

Last Name(Required)

Phone Number(Required)

Email Address(Required)

Preferred Day(Required)

Preferred Time(Required)

:

AFFORDABLE DENTISTRY IN FAIRFIELD

It’s important to find a dentist who offers high-quality work at an affordable price. At Jack Vayner DDS, we do just that. Our range of expertise includes a variety of preventive, restorative, and cosmetic treatments — so you can get every family member taken care of in one convenient location. With treatment variety and financial flexibility, getting the dental care you need has never been easier. Schedule your visit with an affordable dentist in Fairfield today!

PAYMENT METHODS

We understand that each patient’s budgetary needs are different. In an effort to make paying for treatment as convenient as possible, we accept a broad range of payment methods. You may pay with:

Cash

Check

AMEX

Discover

Mastercard

Visa

Don’t see your preferred method of payment listed here? Call to speak with a member of our team for more information!

WE ACCEPT

Dental Insurance

We’re an insurance-friendly practice and we’re in network with several providers. To eliminate additional steps on your end, we’re happy to track, file, and update your claims for you. Rest assured, our goal is to minimize your out-of-pocket expenses and maximize your coverage.

Dental Savers Plan

For those without insurance, we also offer our in-house dental savers plan. For just $25 per month, this plan is designed to cover your routine preventive care and give you discounts on additional dental treatments. Plan membership includes two exams, x-rays, and cleanings, as well as one emergency exam.

CareCredit ®

For additional assistance with out-of-pocket expenses, we also offer customizable payment plans through CareCredit. This financing option functions like a credit card, but can only be used for healthcare expenses. You’ll be able to cover the cost of treatment upfront and pay for your care over an extended period of time. Apply today!

DENTAL SAVERS PLAN VS. DENTAL INSURANCE

Our patients often inquire about the difference between a dental savers plan and dental insurance. The answer is simple — a dental savers plan helps you save on your routine preventive care and additional treatments without the hassles of insurance. Your payments will be made directly to us, and you’ll never have to worry about insurance claims again. Say goodbye to minimums, maximums, waiting periods, and denied coverage!

DENTAL SAVERS PLAN

Are the costs of dental treatment creating a roadblock in achieving your best smile? At Jack Vayner DDS, we understand the cost of treatment is one of the leading causes of why people avoid receiving the dental care they deserve. Our team developed a simple in-house dental savers plan to help save our patients' money and get great care without the hassle of insurance.

Save on Your Smile

LOW MONTHLY PAYMENTS

For just $25 dollars a month, you can save money on preventive care exams and treatments. Our plan is designed to cover your yearly, routine preventive care to make sure your teeth and gums stay healthy. You will also receive additional dental treatments at a discounted rate. Below are some of the yearly savings you will receive:

Two X-Rays

Two Cleanings

Two Exams

One Emergency Exam

NO INSURANCE? NO PROBLEM!

Our Dental Savers Plan saves you the hassle of having to worry about insurance claims, minimums, maximums, or waiting periods. You won’t have to worry about getting denied on your treatments. The best part? The benefits of our plan start immediately, so you would be able to use them at the same appointment.

Call our office today and save right away!