New Patient Form

Step 1 of 9

New Patient Information

First Name(Required)

Last Name(Required)

Email(Required)

Your Gender(Required)

Birth Date(Required)

Main Phone(Required)

Cell Phone (If different than main)

Personal Information Consent Form

We are committed to protecting the privacy of our patients’ personal information. Collecting, using and disclosing all personal information will be done in a responsible and professional manner and in accordance with The Personal Information Protection and Electronic Documents Act and Health Information Act.

We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers, cell phone numbers, and e-mail addresses. (Collectively referred to as “Contact information”) Contact Information is collected, shared with all family members and used for the following purposes:

• To open and update patient files.

• To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts.

• To process claims for payment or reimbursement from third-party health benefit providers and insurance companies.

• To send reminders to patients concerning the need for further dental examination or treatment.

• To send patients informational material about our dental practice.

• To confirm appointments

Contact Information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf.

Financial information may be collected in order to make arrangement for the payment of dental services.

We collect information from our patients about their health history, their family health history, physical condition, and dental treatments. (Collectively referred to as “Medical Information”) Patients’ Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.

Patients’ Medical Information is disclosed:

To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or bas asked up to submit a claim on the patient’s behalf.

To other dentists and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining the second opinion.

To other dentists and dental specialists if the patient, with their consent, has been referred to us to the other dentist or dental specialist for treatment.

To other dentist and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion.

To other health care professionals such as physicians if the patient, with their consent, has been referred to us to the other health care professional for either a second opinion or treatment.

The Health Information Act is designed to facilitate the sharing of health information, in a controlled way, within a “circle of care”. Those that are in the circle of care include; dentists, dental specialists, personal physicians, nursing homes, Alberta Health and Wellness and Alberta Health Services. Disclosure outside of this circle of care is strictly controlled. You may at any time designate any restriction as to whom we may disclose your personal information or restrict the content of disclosure.

If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.

Dentists are regulated by the Alberta Dental Association and College, which may inspect our records and interview our staff as part of its regulatory activities in the public interest.

This is to certify that I, undersigned, consent to the performing of the dental procedures agreed to be necessary or advisable, and I will assume responsibility for fees associated with those procedures.

In addition, I consent to the collection, use and disclosure of my personal information as set out above.

I also agree that any images/video taken of me, excluding dental records and x-rays, may be used in whole or in part for promotional purposes online or in print. In compliance with Canadian Anti-Spam Laws, you understand that by signing this form, you give us permission to send you information such as appointment reminders, appointment confirmations, news and events.

Information retention and destruction

We will retain your personal information for the period necessary to continue providing oral health services to you, and for its related administration. We will destroy information in a secure manner when the information is no longer necessary for the provision of oral health services and is not required to be retained for compliance with provincial or federal regulations or statues.

Your access to your records

We are committed to providing you with open access to your personal information held by us. You may at any time ask (in writing) to see your records held by us and to request amendments to that information.

Complaint Process

Should you wish to make a formal complaint regarding our privacy practice, please do so in writing to our privacy officer, Samantha Bath.

Contact

Should you have any questions, comments or concerns, please bring them to the attention of our privacy officer Samantha Bath. We will be pleased to assist you.

Financial Policy and Agreement

Thank you for choosing us for your dental needs. Our financial arrangements are based on an open and honest discussion of recommended treatment options, respective fees and patients’ financial abilities. To confirm your understanding with our policies, please read the following.

Dental Treatment

Dental treatment fees given are based on the treatments anticipated at the initial comprehensive examination. Some teeth may have hidden decay, fractures, affected nerves or other unanticipated conditions requiring more extensive dental treatments. In situations where additional charges are involved we will explain the reason for additional treatment and their respective fees prior to the services being rendered.

Dental Insurance

We wish to stress that the financial responsibility for services rendered rests with the patient and his/her family; regardless of any insurance coverage. Please understand that dental insurance is a contract between the patient and the insurance carrier, and not between the insurance carrier and the dentist. As a convenience to you, our office will submit charges to your insurance carrier. We urge you to be fully aware of the provisions of your policy since insurance coverage varies dramatically.

Authorization and Release of Information(Required)

I (patient, parent or guardian) certify that I have read and understand the above information to the best of my knowledge and that the dental and medical profiles I have provided are complete and accurate. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered during the period of such dental care to third party payers and or health practitioners for the purpose of administering claims. I authorize the release of information contained in claims to be submitted electronically to my insuring company plans administrator.

I accept

Payment Authorization(Required)

As a benefit to our patients, our office offers no interest payment plans. Payment plans are not available on initial visits. Our payment plan structure is 35% of balance due on the date of service and the remaining balance split over three months/or the remainder of treatment. A valid credit card is needed on file before treatment in order to proceed with a payment plan. A $50.00 NSF charge + 8.5% interest will be applied to your account if we are unable to process the payment. Financial Consent : I am aware that any unpaid balances over 90 days without any financial arrangements in place are sent to a third party collection agency. I give permission for claims and pre-authorizations to be sent manually and/or electronically to my insurance. I understand and agree, regardless of my insurance status, I am ultimately responsible for any unpaid balance on my account.

I accept

Short Notice Cancellation and No Show Policy:(Required)

Changes to existing dental appointments are accepted within 2 days’ notice for Monday to Friday appointments and 3 days’ notice for Saturday and Sunday appointments. When less notice is given, this may result in a deposit being required to pre-book any future appointments. Thank you for your understanding of our policy. This question is required. *

I accept

New Patient Form

New Patient Information

Patient Information

Emergency Contact Details

Insurance Information

Primary Insurance

Patient Dental History

Patient Medical History

Women Only

X-ray And Record Release

Personal Information Consent Form

Signature of Approval

FREE Parking On Site!

Now accepted at Central Dental Family Dentistry! ✓ Coverage for routine checkups, cleanings & care ✓ Financial support for restorative treatments ✓ Designed to make dental care more affordable and accessible

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