Sign up for appointment
The patient acknowledges that dental insurance is an agreement between the patient and the insurance provider. Any portion not paid by the insurance company is the responsibility of the patient and is due in full at the time of service.
The patient understands that insurance companies may apply arbitrary determinations regarding usual and customary fees, and that the dental office is not responsible for tracking plan maximums, frequencies, limitations, or eligibility.
The patient acknowledges responsibility for verifying insurance coverage directly with the insurance provider.
The patient understands that statements issued by the office are subject to a 30-day interest-free grace period. After 30 days, interest may be applied at 18% per annum. Accounts not cleared may result in postponed future appointments.
Accepted payment methods include cash, debit, VISA, MasterCard, and American Express. Personal cheques are not accepted.
The patient acknowledges and consents to the collection, use, and disclosure of personal information for purposes including, but not limited to:
Providing safe and effective dental care
Communication, scheduling, and follow-up
Billing, insurance claims, and account management
Regulatory and legal compliance
Coordination with other health care providers
Teaching or demonstration purposes on an anonymous basis
The patient understands that personal medical history will not be released to insurance companies without explicit consent, and that consent may be withdrawn subject to applicable legal requirements.
The patient acknowledges the appointment cancellation policy requiring two business days’ notice, and understands that failure to comply may result in fees, deposits, or restricted booking privileges.
Full Name *
Email Address *
Draw your signature *
