Please click on the forms below in order to print them out.  You may fill them out at your convenience and bring them with you on your first visit.

  1. Patient Information Form
  2. Consent for Services
  3. Privacy Practices & HIPPA
  4. Pre-Visit Questionnaire
  5. Consent for Dental Treatment
  6. Financial Consent Form

We are happy to assist you if you have Dental Insurance.
We are considered an Out-Of-Network Dentist in all Dental Plans. However, we will gladly prepare and submit, at the patients request, any claim forms or assist in making collections from Insurance Companies on our patient’s behalf.  Dental Insurance coverage is totally dependent upon which type of dental plan you or your company has selected.  In our office, we will provide you with the best dental care that we are capable of doing, so that your best interest is served and we are able to maintain our high standards.  Please check with your Dental Insurance Co. to see if you have coverage in an Out-Of-Network office.  Bring your most current insurance ID card.

For new patients, complete the Medical/Dental History questionnaire in the privacy of your home and bring it with you to your first first appointment.  We need this information so we can treat you safely.

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Kieu M. Le, D.D.S., PLLC
Sunset Hills Professional Center
11351 Sunset Hills Road
Reston, Virginia 20190

Telephone:  703.709.0330
Fax:  703.689.4086
E-mail: 
info@drmercantini.com