• Mon - Thu: 08.00am to 05.00pm
  • Fri : 08.00am to 01.00pm
  • Contact : +1(574) 232-2992
  • Email : kosekdds@sbcglobal.net
  • Mon - Thu: 08.00am to 05.00pm
  • Fri : 08.00am to 01.00pm
  • Contact : +1(574) 232-2992
  • Email : kosekdds@sbcglobal.net
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  • Acknowledgement
  • Office & Financial policy
  • Patient Medical history
  • Patient Dental history
  • Patient Information
  • Responsible Party
  • Insurance Information

Acknowledgement Of Receipt

I acknowledge that I received a copy of DK Dental’s Notice of Privacy Practices.

Office & Financial Policy

Thank you for choosing the dental office of Douglas J. Kosek D.D.S. where your oral health is our number one concern. We will make every effort to ensure that all fees are fair and reasonable. In order to reduce any confusion or misunderstanding we have adapted to the following policies.

*Please provide your current dental insurance before your appointment. If you need more plan specific information about your benefits please contact your insurance carrier.

* We are in network with Delta Dental, Cigna ,Health Resources, Guardian, and MetLife . As a courtesy we do file to a variety of other insurances excluding Medicare and Medicaid.

* Monthly statements will be sent to all accounts , even those with pending insurance and orthodontic balances.

* A $25 fee will be assessed to all returned personal checks. Any returned check must be taken care of to avoid being turned over to a collection agency.

*All delinquent accounts that carry a balance for over 90 days will be turned over to a collection agency unless proper arrangements have been made. We utilize a collection agency [Capital Accounts & Diamond] when we cannot make arrangement with patients for payment on the account, Once turned over you will be responsible for taking care of your balance and any collection fees incurred.

* A 24-hour cancellation is required for all appointments, please keep in mind that this is a spot taking up your hygienists and/or doctors time.

*All payments including copays and deductables are due at the time of service , unless prior arrangements have been made.

*For patients 17 years and younger a patient or guardian must accompany them and sign the Office Policy from {exception, parents under 17 of age declared anticipated minors }. It is the parent/guardian’s responsibility to bring the necessary insurance card and to make any payment due at the time of service.

"I have read, understand, and agree to the office & Financial Policy." Terms and conditions

Patient Medical History

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Patient Dental history



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Patient Information(Confidential)

1) Minor 2) Single 3) Married 4) Separated 5) Divorced 6) Widowed
1) Full Time 2) Part Time

Responsible Party

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1) Cash 2) Personal Check 3) Credit Card 4) VISA 5) MasterCard 6) I wish to discuss the Office's payment policy

Insurance Information

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NEW PATIENT PAPERWORK
Appointment

  • Modern dentistry
    in a calm and
    relaxed atmosphere.
    We maintain a highly trained, qualified, and experienced team.
    Contact Us
  • Many smiles
    Since 1997
    Our dentists give you the best of modern dental care.
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  • The healthy smile
    through science
    and design.
    Meet Our Doctors

Welcome to DK Dental

Design Your Smile With Us

DK Dental has been practicing in the downtown South Bend area for well over 23 years. We provide modern dentistry in a calm & relaxed atmosphere.. Our office has two dentist that give you the best of modern dental care. Our doctors maintain a highly trained, qualified and experienced staff. Here at DK Dental we strive to make our patients feel like family.

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ADVANCED DENTISTRY

Using the latest technology and methods we are able to serve happiness to each patient.

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Quality Equipment

We use high end, quality equipment, that is state of the art.

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Comfortable Office

Patient's comfort is out top most priority.

Specialities

DK Dental Services

Your teeth play an important part in your daily life. It not only helps you to chew and eat your food, but frames your face. Any missing tooth can have a major impact on your quality of life.

Aesthetic Dentistry

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Orthodontics

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Laser Dentistry

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Tooth Whitening

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Testimonials

What Our Customers Say?

Your teeth play an important part in your daily life. It not only helps you to chew and eat your food, but frames your face. Any missing tooth can have a major impact on your quality of life.

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It was an experience of lifetime with you guy. It is definitely the best dental clinic I have ever visited. Now I’ve got my tooth back thank you DK Dentist.

Evelynne Mirando

SouthBend
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Thank you DK Dentist for doing my cosmetic dental treatment. After consulting so many, I have decided to get it done from DK Dentist. I am very happy for my new smile which will help me to enhance my personality. Thank you very much.

Jonathan Lee

Mishawaka
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Awesome. Loved the all staff. I was actually comfortable during the procedure of the filling. Didn't feel a thing. Everyone was so nice from the moment you walk in to the moment you leave.

Daniell Mirando

Granger
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