Office Forms

Please Download the appropriate form, print it, fill it out and bring to our office.

At Zionsville Pediatric Dentistry, we make every effort to keep down the cost of dental care.

You can help by making your payment at the time of your visit. You will be given an estimate of the approximate

total fee at the beginning of any necessary treatment and definite financial arrangements will be made with you

at that time. Services rendered on your child’s first visit must be paid that day. We have a few payment options

for your convenience:


Payment with cash or check the day of service


MasterCard, Visa


Insurance – We will file insurance claims as a courtesy to you at no charge. You must provide us with a current insurance card that shows mailing address and telephone number for benefit determination.


CareCredit – CareCredit is a flexible patient payment program, specifically designed for healthcare expenses that make it easier for your child to get the treatment or procedures they need. CareCredit lets you begin your treatment or procedure immediately-then pay for it over time with low monthly payments that easily fit into your monthly budget. Please visit www.carecredit.com or ask our front office staff for more information.


Zionsville Pediatric Dentistry, Dr. Melissa McHenry DDS, MSD

55 Brendon Way, Suite 500  - Zionsville, IN 46077