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5 Year Medical Update Form adentaloffice.com

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Gender

Preferred Gender Pronoun

A pronoun is a word that substitutes for a noun; in this case, a word that substitutes for your name. We want to know what to call you!

Contact Information

Medical & Dental Information

Do you or have you ever had an adverse reaction or allergy to:

Have you ever had any of the following? Please check those that apply:

If you had any surgeries please specify the surgery date and information.

Consent for Services & Office Agreement

* I understand that my family’s appointments are valuable, and that 2 Business days must be given if we are unable to attend appointments. A missed standard appointment may incur a fee.

*I will be required to pay for my family treatment at each visit. For treatment involving laboratory work, I will be required to place a deposit for the estimated lab work required (this is separate from Dental office fees).

*I understand that outstanding account balances will be passed to a Credit Agency and/or to the Ontario Court System.

*I understand there are premium times in great demand. If I am not attending these premium appointments and thus preventing other patients from making effective use of these times, I will be required to make use of regular hours for treatment.

*My dental insurance plan is a contract between myself and the organization providing me with the coverage.

It is my responsibility to ensure that the treatment I request is covered. However, adentaloffice.com will help me to the best of their abilities to ensure accurate and timely completion of my insurance forms. adentaloffice.com has NO knowledge of what is covered by my insurance plan. If I have a booklet, adentaloffice.com will be able to interpret it for me. Many plans require Pre-Determinations to be forwarded for more extensive treatment. adentaloffice.com will complete these for me. To avoid any delays in receiving my payment from my insurance company I must send my claim immediately, if it is not submitted electronically.

* adentaloffice.com also understands that your time is valuable so we are intent on starting your appointment on time. With the possible exception of short notice emergencies (which all of us might get and we would like to be seen as soon as possible) we will not double book appointments.

* adentaloffice.com will always make every attempt to see emergency cases promptly.

* adentaloffice.com will accept Visa, MasterCard, debit and cash.

* adentaloffice.com will propose my dental treatment with my long-term dental health in mind, and will do their best to give an accurate estimate.

Consent for Collection, Use and Disclosure of Personal Information

* I agree that adentaloffice.com has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. I can request to see a copy of the consent form and agree the personal information may be collected, used and disclosed as set out in the Privacy Policy of the Office which is in accordance with the Personal Health Information Protection Act, 2004.