The information that is requested on this questionnaire, dental history and medical history is essential to providing you with the highest standard of dental care. The protection and privacy of your personal information is important to our oﬃce and we are committed to collecting, using and disclosing this information responsibly.
We require each patient to read and sign our office introduction prior to treatment.
Our office offers a variety of payment methods for your convenience. In addition to the traditional payments via cash, cheque, debit, MasterCard, VISA, EFT and online bill payments, we have financing options available through Dental Card 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.
Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. As a courtesy to you, our office can send a pre-treatment estimate to the insurance company at your request. It is impossible for us to have knowledge and keep track of every aspect of your insurance. It is up to you to contact your insurance company and inquire as to what benefits your employer has purchased for you. It is your responsibility to have any questions concerning the pre-treatment estimate and/or fees service answered prior to treatment to minimize confusion.
Please be aware that the treatment we recommend is based on your individual needs and never on what your insurance covers. Some or perhaps all of the services provided may or may not be covered by your insurance policy. Any balance is your responsibility whether or not your insurance pays any portion.
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.
We require each patient to read and sign our patient communication preferences prior to treatment.
This information will enable us to maintain communication with you.
Patients with ODSP, NHIB, or Ontario Works beneﬁts, please call our oﬃce for more information about your coverage.
This information will enable us to make any essential contacts.
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tel: 613-435-4131 Fax: email@example.com