New Patient Intake Form

This information will enable us to make any essential contacts

We require each patient to read and agree to our patient communication preferences prior to treatment.

Appointment Confirmation Preference:

Our office offers a variety of ways to stay connected to our office. You may select more than one option that suits your lifestyle best:

Promotion Communication Preferences:

Our office provides various patient appreciation events throughout the year and we often host various promotions and like keeping our patients informed about the various activities we get ourselves involved in as well as events we would like to involve you in. Please let us know your promotional communication preferences:

Please DO NOT include me in your mailing list ( NOTE: this excludes any direct mail that comes to you via Canada Post. We mail out based on postal code and cannot individually select which home it goes to )

We require each patient to read and agree to our office introduction prior to treatment..

Payment Methods:

Our office offers a variety of payment methods for your convenience. In addition to the traditional payments via cash, cheque, MasterCard, VISA, EFT and online bill payments, we have financing options available through Paybright Financing. Our goal is to help you secure the treatment you need while providing options that fit your budget. If you have questions, please ask one of our front desk team members to explain your options.

Insurance:

Our front desk team is well trained and knowledgeable in third party payment issues. As a service to our patients, we are happy to file your dental insurance claims electronically for you. We will accept insurance benefits provided all paperwork and necessary information is complete. We do require that deductibles and co-payments be paid at the time of service. Your insurance policy is a contract between you, your employer and the insurance company. Any fees not covered by your insurer will be your responsibility and an estimate of your portion is the amount expected at the time of service. All balances are due upon receipt.

Appointments:

We would like to convey to you the importance of your scheduled appointment time. Our appointment times are specifically reserved for each patient. We require the courtesy of 2 business days advance notice by phone should you need to cancel or change your appointment. This courtesy allows us to give your appointment time to patients who may be waiting.

• Patients who fail to arrive for their appointed time or who do not provide required advance notice will be subject to a $50 fee.
• We request that you call during office hours to reschedule or cancel appointments. Please do not leave messages to cancel appointments as our system does not recognize this as a cancellation and you will be subject to a $50 fee.

Thank you.

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. Should there be any change in either my health status or any other health information I have provided, I will advise this dental office. I authorize the dentist to perform diagnostic procedures as may be required to determine the necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.