New Patients Form

The following information is required to enable us to fully evaluate your dental history and provide complete options for your future care based on both your dental requirements and your satisfaction with your teeth

We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use, and disclose. In addition to the circumstances described in this form, we also collect, use, and disclose personal information when permitted or required by law. We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers, cell telephone numbers, and email addresses. (Collectively referred to as “Contact Information”) Contact Information is collected and used for the follow purposes: To open and update patient files To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts To send reminders to patients concerning the need for further dental examination or treatment To send patients informational material about our dental practice 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 arrangements 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 or all or part of the cost of dental treatment or has asked us to submit a claim on their 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 by us to the other dentist or dental specialist for treatment -To other dentists 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 by us to the other health care professional for either a second opinion or a treatment 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. I authorize Macleod Trail Dental/South Centre Dental to communicate on behalf of myself and all dependents named on my insurance plan, with my insurance company and/or plan administrator with which I may at any time have coverage. I authorize release of personal/financial/dental/medical Information to the same.

We do require 48 hours’ notice to change or cancel an appointment. It is our policy to personally confirm your appointment prior to the appointment date. Should we be unable to reach you directly or leave you a voicemail, please return our call to confirm your appointment, or your appointment will be at risk of being lost.

We understand that life can be unpredictable, and unforeseen events may arise and you may need to cancel or reschedule your appointment. We kindly ask that you give us at least 48 hours notice if you need to cancel or reschedule your appointment, to give us the opportunity to offer that time slot to another patient. If 48 hours notice is not provided or you do not show up for your scheduled appointment, we will require a deposit of $100 to schedule another appointment. This deposit will be applied to the cost of your next appointment or reimbursed back to you at the time of the appointment. In the event that you short notice cancel or no show to that appointment the deposit will be forfeited. We understand that emergencies and illness can happen. We will do our best to be understanding in these situations. However, we ask that you please communicate with us as soon as possible if you need to cancel or reschedule your appointment outside of our cancellation policy. Thank you for your understanding and cooperation in keeping our schedule running smoothly. If you have any questions or concerns about our cancellation policy, please do not hesitate to ask us. I have read and understand the above cancellation policy. By signing below, I acknowledge that I am responsible for adhering to this policy and agree to pay the deposit of $100 if I fail to provide the required notice or no show to my appointment.

Welcome to Macleod Trail Dental. You have many choices when it comes to choosing a dental office. Everyone at our office is committed to providing quality dental care in a comfortable and safe environment. Please take a few minutes to familiarize yourself with our office’s policies. Although many dental offices are non-assignment, our office will accept direct billing of benefits from your insurance company as part of our patient services. It is important for you to understand that there may be a difference between our fees and what your insurance company will pay for treatment. You are responsible for any difference in fees, with special exceptions for our patients who are covered by a low-income or government assistance plan. The same policy applies to those patients who have coverage through two insurance companies. In order for our office to direct bill with your insurance we do require a form of payment on file in case there is an outstanding balance that could not be collected at the time of the appointment. Once the insurance portion has been collected any balances under $100.00 will be charged to the credit card on file and a receipt will be sent to you. If the charge is over $100.00 you will be contacted by phone or email before the charge is placed. If we do not hear back from you within 2 weeks the charge will be processed on your credit card and a receipt will be sent to you.

Please note that not all procedures will be covered by your insurance or covered exactly to the percentage specified on your plan. Each individual insurance plan has its own fee guides, rules, and exceptions which are negotiated by your employer. These differences are your responsibility to understand and follow. Our office will do our best to assist our patients in understanding the details of their insurance plan; however, we are limited in the information we can access due to privacy laws and it is ultimately the patient’s responsibility to understand their insurance plan, annual maximums, eligible benefits, and covered procedures.

Treatment fees for dental services vary from patient to patient, therefore any and all fee estimates given before being assessed by a dentist and/or hygienist are estimates only and could be substantially more or less at the time of billing. Fee estimates given are only reliable if you have seen the dentist and/or hygienist who has given one of our dental administrators your treatment plan.

We hope that your experience with us will exceed your expectations.  If we can help in any way, please do not hesitate to ask.

I give Macleod Trail Dental consent to have my credit card on file and consent to charging the credit card for balances owing after insurance has been collected.

Helcim is a payment processor that lets businesses accept credit cards. All credit card information, including CVV, is stored with the compliant and secure Helcim commerce merchant platform. We store your credit card information into Helcim Card Vault and shred this form.

I hereby certify that the medical and dental history is accurate and complete, to the best of my knowledge. I consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetics or any drugs as indicated and I will assume responsibility for all fees associated with those procedures. My signature on this form authorizes submission, including electronic submission and direct assignment, where allowed, for claims for dental services provided. I consent to the collection, use and disclosure of personal information as described herein. I have read and understood the foregoing and agree to the terms and conditions stated herein.