Information for Our Patients
If you are a new patient to our Houston dental office, the forms below will need to be filled out when you arrive for your first appointment in our office. Printing them, filling them out, and bringing them with you will allow us to attend to your dental needs more quickly than completing them upon your arrival.
New Patient Welcome Forms 2021
This website uses files in Adobe Acrobat Portable Document Format (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.
Emergency Care:
Sometimes a tooth will act up suddenly and you find yourself in immediate need of a dentist. We allow time in our schedule to accommodate dental emergencies, and you will receive an appointment on the same day you call.
Payment Options:
For your convenience, we accept cash, personal checks and major credit cards including, VISA, MasterCard, AMERICAN EXPRESS & DISCOVER. Payment is expected at the time services are rendered. When more extensive dental care is necessary, financial arrangements can be made at our office.
Insurance
As a service to our patients, our practice accepts most dental insurance programs, including non-managed care and PPO out-of-network. We are not part of any managed care network. Our accounting staff will prepare all the necessary forms for your dental benefits. However, we remind you that your specific policy is an agreement between you and your insurance company. Please keep in mind that you are responsible for your total obligation should your insurance benefits result in less coverage than anticipated. Our staff will gladly submit a pre-treatment estimate to your insurance company so that you will know what your benefits will be.
The fees charged for services rendered to those who are insured are the usual and customary fees charged to all our patients for similar services. Your policy may base its allowances on a fixed fee schedule, which may or may not coincide with our usual fees. You should be aware that different insurance companies vary greatly in the types of coverage available. Also, some companies take care of claims promptly while others delay payment for several months.
See Why Patients Trust Dr. Ly & Copperfield Smiles
Schedule Your Appointment Today!
Ready to take the next step toward a healthier smile?
Use the form to request an appointment with Dr. Ly and the Copperfield Smiles team. Whether you’re a new or returning patient, simply fill out your contact details and let us know how we can help. Our staff will reach out shortly to confirm your appointment and answer any questions you may have.
Need to be seen today?
For dental emergencies, please call us directly at (281) 550-7276 to check for same-day availability.
We offer emergency exams and X-rays for just $79 — no insurance required.
We look forward to helping you smile again soon!
Simple, Flexible Payment Options at Copperfield Smiles
At Copperfield Smiles, we believe your smile shouldn't have to wait because of finances. That’s why we offer flexible payment options designed to fit your life — with our preferred partner, Cherry, leading the way.
✅ Pay Over Time with Cherry
We’ve partnered with Cherry to make it easier than ever to say yes to the care you need — from emergency visits to cosmetic upgrades.
With Cherry, you can:
✔ Split your treatment into manageable monthly payments
✔ Apply in seconds with no hard credit check
✔ Choose from 3 to 24-month plans
✔ Enjoy 0% APR for up to 24 months (on qualifying plans)
✔ Pay early anytime with no penalties
For example, a $1,200 payment plan with Cherry may cost $100/month over 12 months at 0% APR, with a $100 down payment due at the time of purchase.
👉 Apply Now with Cherry (https://pay.withcherry.com/copperfield-smiles-dental)
It’s fast. It’s flexible. And it gets you smiling sooner.
💡 Need an Alternative?
For select procedures, we may offer an in-house installment plan split over 3–4 payments. Our team can review this option with you during your visit if applicable.
📞 Questions? Call (281) 550 -7276, and we’ll walk you through what works best for your smile and your budget.
Your health and confidence matter — let’s make getting the care you need simple and stress-free.
