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181 N Main St Wallingford, CT 06492 | Get Directions

New Patient Forms

Why wait to fill out these forms in our waiting room when you can fill everything out easily, and at your own speed at home.

Save time before you come in to visit us. Download, print, and fill out these forms at your convenience before your first appointment, and then bring them with you to your appointment. If you have any difficulty filling out or locating all of our forms, please feel free to give us a call. We’re always happy to help.

New Patient Forms

Main Street Dental Comprehensive Dental Plan

You can afford the smile you’ve always deserved with the Main Street Dental In-House Comprehensive Dental Plan

Why would we ever want to put a frown on your face when it’s our job to make you smile? Even if you don’t have insurance, there is another great way you can afford the smile of your dreams: with Main Street Dental’s In-House Patient Finance Plan.

Main Street Dental’s Comprehensive Dental Plan is designed to provide affordability and greater access in dental care. With your Comprehensive Plan there are:

  • No yearly maximums
  • No Deductibles
  • No claim forms
  • No pre- authorization Requirements
  • Immediate eligibility

Benefit Premiums

Total Amount Cost
Single $303
Dual $589
Family $1122

*The dual Plan is for Parent/Child or Husband/Wife only.
**The family plan includes children who are enrolled full time in college until age 23, or children who are not enrolled full-time in college until age 18.

You will not receive a membership card—your plans effective date will be on file with our receptionist!


Diagnostic & Xrays

Treatment Member Discount
Comprehensive Exam
(new patient, initial exam)
Periodic Exam
(2 per year)
Limited Oral Exam
Problem Focused
(1 per year)
Intraoral-Complete Series
(1 every 3 years)
Intraoral Periapical
First film
Intraoral Periapical
Each Add. Film
(1per year)


Treatment Member Discount
Child/Adult Prophy-Laxis
2 per year after $6 Co-pay
1 per year, no age limit
After $5 Co-pay
Sealants 50%
Space Maintainers 50%

All Other Procedures

Treatment Member Discount
Fillings 25%
Crown Periodontics
(General Dentistry)

Program Exclusions and Limitations

This program is a discount plan, not a dental insurance plan, and is secondary to any other dental plan.

It cannot be used:

  • In conjunction with another dental plan.
  • For services for injuries covered under workman’s compensation.
  • For treatment which, in sole opinion of the treating dentist, lies outside the realm of the capability.
  • For referrals to specialists.
  • For hospitalization or hospital charges of any kind.
  • For cost of dental care which is covered under auto medical.
  • With senior discount.

This plan is only honored at Main Street Dental. It is not an insurance plan that can be used at any other dental office.

Program Guidelines

There will be a $50 reinstatement fee if your plan lapses.
Cannot be used in conjunction with another dental plan.

No refunds or premiums will be issued at any if time participant decides not to utilize dental plan.

Plan expires one year from date of purchase.

Insurance & Financing

Our team can help you maximize your insurance benefits to get you the care you deserve

Trudging through the insurance quagmire is beyond frustrating and it takes so much time and effort, so that’s why our practice will help you navigate your benefits to maximize your current insurance plan so you are getting the care you want, and the smile you’ve always dreamed of. Call us today to find out how we can help!

Anthem BlueCross BlueShield
Delta Dental

Online Payments

We make paying for your new smile easy!

You can safely and securely pay for your treatment through our online portal. Your information is safe with us. No need to wait. When you’re ready, we can take your payment right here:

Pay Now

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