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New Patient Forms

To help you with your visit, we have put the forms you need to fill out here on our site. Just print them out, fill in the information and bring them with you to your appointment. If you have any questions you can give us a call or check with us when you come in for your appointment.

Patient Information

Medical History

Elite Smiles Club

No Insurance? We've Got You Covered.

At Elite Smiles of Louisville, we value our patients above everything else. Our main priority is to strengthen the relationships between our patients and our practice.

We understand the financial hardship that dental costs can impose. That’s why we are offering a discount plan for our patients without insurance. We believe great smiles can be achieved at a reasonable cost, and we have designed our discount plan to reflect this philosophy.

Our patients will pay as little as $32 a month and receive 100% coverage on a variety of services including cleanings, emergency exams, and X-rays. We even provide discounts on our cosmetic procedures for members of our plan.
We hope that by offering a discount plan to those patients without dental insurance, we can focus on improving oral health without burdening our patients with financial stress.

We think you will agree that this plan is a great way to save money while still receiving top-notch care at Elite Smiles of Louisville.

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Why Our Plan Is Better

• No Deductible
• No Yearly Maximum Coverage
• No Forms for Claims
• No Waiting Periods
• Exams & X-Rays Covered
• Substantial Discount on Cosmetic Procedures
• All procedures discounted

What Does the Elite Smiles Club Cover?

Diagnostic & X-Rays

 100% Comprehensive Exam
• 100% 1 Annual Exam
• 100% 1 Emergency Exam
• 100% 4 Bitewing X-Rays
• 100% Periapical, FirstFilm
• 100% Periapical, Each Additional Film
• 50% Complete Series X-Rayor Panorex


• 100% Child Prophylaxis (2 per yr)
• 100% Adult Prophylaxis (2 per yr)
• 100% Fluoride
• 100% Oral Cancer Screen (1 per yr)
• 50% Sealants
• 20% Additional cleanings (after 2)

All Other Procedures

• 20% Fillings & Core Buildups
• 20% Oral Surgery
• 20% Root Canals
• 20% Crowns
• 20% Periodontal procedures/ SRP’s
• 20% Dentures and partials
• 10% Veneers/cosmetics
• 10% Implants
• $100 off In-Office Whitening
• $50 off Take-Home Whitening Trays

Monthly and Annual Pricing Plans


$362 annual cost
  • $32

  • /MONTH


$650 Annual Cost
  • $60

  • /MONTH

Family (4)

$892 Annual Cost
  • $94

  • /MONTH

Interested in learning more about the Elite Smiles Club?
Please give us a call at 502-895-5440 to apply!

Accepted Payments

Elite Smiles of Louisville offers several payment options including cash, check, Visa, Mastercard and Care Credit Patient financing.
To learn more about our services or set up an appointment or consultation, call us at 502-895-5440 or e-mail us with your request and we’ll give you a call back to set up your visit.

Our Location

Elite Smiles of Louisville
6400 Dutchmans
Pkwy #135
Louisville, KY 40205
Phone: (502)895-5440

Hours of Operation

Monday 8am – 5pm
Tuesday 8am – 7pm
Wednesday 8am – 5pm
Thursday 8am – 5pm
Friday 8am – 3:30pm
Saturday 8am – 1pm one Saturday/month
Sunday – Closed