Financial Information
Dental History
Reason for today's visit:
Medical History
Informed Consent
-I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care.
- I authorize release of any information concerning my (or my child's) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits.
- I authorize release of any information concerning my (or my child's) health care, advice and treatment to another dentist
- I authorize payment of insurance benefits directly to the dentist or dental group, otherwise payable to me.
- I understand that my dental care insurance company may pay less than the actual bill for services. I understand I am financially responsible for payments in full of all accounts. By signing this statement, I agree to be responsible for payment of services not paid, in whole or in part by my dental care payer.
- I authorize the setting up of my dental file, its follow-up, as well as my registration on the recall list(s) of the treating dentist(s).
- I have been informed that my file will be kept in the office at all times and that only the dentist(s) and his/her (their) auxiliary personnel will have access to it.
- I attest to the accuracy of the information on this registration form.
· We will help prepare insurance claim forms and assist in requesting reimbursements from insurance companies on behalf of our patients. Not all services may be covered by dental insurance and every plan has its own unique quirks and exceptions. We will do our best to help you clarify your plan. However, it is the patient’s responsibility to understand his or her own dental insurance benefits. Unless otherwise agreed upon, services are to paid for at each visit as they are performed.
· Please help us in providing the very best of service by remembering that once you have made an appointment this time is reserved for you. Therefore, we require a minimum of 48 hours notice (2 business days) if an appointment must be cancelled or rescheduled. A fee may be charged for cancelled or missed appointments without sufficient notice. Please note that insurance companies do not cover fees for broken appointments. Therefore such fees are the patient’s responsibility.
Medical / Dental Informed Consent
I, the undersigned, certify that I have provided, to the best of my knowledge, an accurate and complete medical & dental history and have not knowingly omitted any information. I consent to my dentist obtaining from other practitioners who are currently treating me or have treated me, such further information as maybe necessary for providing me with proper dental treatment and care. I hereby promise to inform my dentist of any changes to my health status.
Signature on File
- I authorize release to my insuring company(s) plan administrator(s) the information contained in claims submitted electronically.
- I hereby assign my benefits payable from claims submitted electronically to Dr. and authorize payment directly to him/her.
Patient Consent Form
Collection, Use and Disclosure of Personal Information
Privacy of your personal information is an important part of our office providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also tried to be as open and transparent as possible about the way we handle your personal information. It is important to provide this service to our patients.
In this office, Dr Kanwar Singh acts as the Privacy Information Officer.
Al! staff members who come in contact with your personal information are aware of the sensitive nature of the information you have disclosed to us. They are all trained in the appropriate uses and protection of your information.
Below is an outline of what our office is doing to ensure privacy protection:
Only necessary information is collected about you and your children.
We only share information with your consent.
Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols.
Our privacy protocol complies with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario.
Collection, Use and Disclosure of Patient's Personal Information
To help you understand the importance of keeping your information private, we have outlined below how our office is using and disclosing your information.
This office will collect, use and disclose the information about you for the following purpose:
To provide health care.
To deliver safe and efficient patient care.
To identify and to ensure continuous high quality service.
To advise you of treatment options.
To enable us to set up a file on you or your children.
To enable us to contact you.
To establish and maintain communication with you.
To offer and provide treatment, care and services in relationship to the oral and maxillofacial dental care.
To allow us to maintain communication and contact you to distribute healthcare information and to book and confirm appointments.
To communicate with other treating healthcare providers, including specialists and general dentists who are referring dentists and/or peripheral dentists.
To allow us to efficiently follow-up for treatment, care and billings either to you directly or indirectly.
To complete and submit dental claims for third party adjudication and payment.
To collect unpaid accounts.
To process credit card payments.
To invoice for goods and services and laboratory services.
For consultations with a specialist for specific treatment modalities such as orthodontics.
For teaching and demonstrating purposes on and anonymous basis.
To comply with legal and regulatory requirements, including the delivery of patients’ charts and records to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of RHPA.
To comply with agreements/undertakings entered into voluntarily by the member with the Royal College of Dental Surgeons of Ontario, including the delivery and/or review of patients’ charts and records to the College in a timely fashion for regulatory and monitoring purposes.
To deliver your charts and records to the dentist's insurance carrier to enable the insurance company to assess liability and quantify damages, if any.
To prepare materials for the Health Professions Appeal and Review Board.
To assist this office to comply with all regulatory requirements and generally with the law.
To permit potential purchasers, practice brokers or advisors to evaluate the dental practice.
To allow potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale.
By signing this consent form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal and/or children information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance.
Your information may be accessed by regulatory authorities under the terms of the Regulated Health ProfessionsAct (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under RHPA, and for a defense of a legal issue.
Our office will not under any condition supply your insurer with your confidential medical history. In the event this kind of request is made, we will forward the information directly to you for review, and for your specific consent.
When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such a release is inappropriate.
You may withdraw your consent on use of your personal/children information at anytime, and we will explain the ramifications of that decision, and the process.
Patient and Guardian Consent
I / We have reviewed the above information that explains how your office will use my/our personal information, and the steps your office is taking to protect my/our information. I know that your office has a Privacy Policy, and I can ask to see the policy at any time.
I authorize Village Dental of Streetsville to perform all dental or diagnostic procedures agreed to be necessary or advisable, including x-rays, photographs, and the use of local anaesthetic or other medications as indicated. I understand that if I miss and appointment or provide less than 48 hours notice to cancel or reschedule an appointment, I may be charged a cancellation fee. I assume full responsibility for fees associated with my dental treatment and those of my dependents. I have read and fully understand the above conditions of treatment and I accept my responsibility as a patient at this office.
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