New Patient Information

Welcome to Alabama Pediatric Dentistry! Dr. Michelle Bajjalieh and her team can’t wait to help children smile brightly throughout every stage of life. Once you’ve scheduled their first appointment, please carefully review the following information so that you know what to expect when your family arrives. Rest assured that we will make this initial experience a safe, comfortable, and pleasant one for your son or daughter.

Patient Forms

Instead of having to wait until you’re physically sitting in our office, parents can get a headstart on all the necessary forms by downloading them here online! Just print them out, complete the requested information, and make sure to bring them with to our Homewood, AL location. Our team members will be able to invite your child back to the treatment room faster as a result.

Patient Information Form

Health History Form

Notice of Privacy Practices

Financial Policy

Insurance and Financial Information

Just as we are committed to providing excellent pediatric dental care, we are concerned about making it affordable to you. Payment is expected for services at the time they are rendered to help control billing and accounting costs. Our office accepts cash, checks, MasterCard and Visa.

We are currently a preferred provider for Blue Cross and Blue Shield of Alabama, United Concordia, Delta Dental, Cigna, Guardian, Aetna, Assurant Employee Benefits, Ameritas, MetLife, Southland, Principal, and Medicaid. Our office is committed to helping you maximize your insurance benefits. Because insurance policies vary, we can only estimate your coverage in good faith but cannot guarantee coverage due to the complexities of insurance contracts. Your estimated patient portion must be paid at the time of service. As a service to our patients, we will bill insurance companies for services and allow them 45 days to render payment. After 60 days, you are responsible for the entire balance, paid-in-full. If you have any questions, our courteous staff is always available to answer them.

Filing of insurance plans is done as a courtesy to our patients. Most plans only cover a portion of the dental fee, which means you will be responsible for your deductible and the estimated co-payment. Your co-payment is expected at the time you are in the office for dental care. Please keep us informed of any changes or updates in your insurance information. The responsible person shown in our records, not the insurance carrier, is financially responsible for payment.