Registration Forms for Dentistry Care
Thank you for choosing Mercy Dental Services!
Mercy Dental Services is located on the second floor of Mercy Medical Center’s Surgery/Cancer Center. We do not accept walk–ins, so please call to schedule an appointment. Emergency appointments are scheduled on a daily basis by calling our office each morning.
All new patients, please download and fill out the following form:
Do You Have Dental Insurance?
Yes, I have dental insurance.
Please call us at 330-471-5950 to schedule an appointment. Please download the patient registration and medical history forms, fill them out, and bring them with you to your first appointment
No, I do not have dental insurance.
If you do not have dental insurance, do you meet the federal poverty guidelines?
If you meet these guidelines and you are UNEMPLOYED, please download and fill out the following forms:
If you meet these guidelines and you are EMPLOYED, please download and fill out the following forms:
Prompt Pay Program
If you do not have dental insurance, but your income exceeds the government’s poverty guidelines, you still qualify for a discounted prompt pay program. This means you will receive a discount by paying the balance owed, in full, at the time of service. Call Mercy Dental Services at 330-471-5950 to learn more.