New Patient Form


We would like to take this opportunity to welcome you to our practice. We look forward to helping you achieve optimum oral health. We are aware that for many people, dental treatment creates a stressful situation and every effort will be made to make you comfortable during your appointments. If there is anything we can do to help you in this regard, please feel free to bring it to our attention.

Our office staff strives very hard to keep on schedule, as we know that your time is valuable. It is therefore essential that you arrive on time for your appointments so that we may continue to be punctual for all of our patients throughout the day. Booked appointments are a mutual agreement. We anticipate that you will make the necessary arrangements to attend the appointment you booked. As a courtesy, reminders for all dental appointments are sent two business days in advance; we ask that you confirm by 4:00pm on the day you receive your reminder. Any short notice changes with less than 2 business days notice or no-shows will be subject to a $100 scheduling fee. Frequent short notice cancellations can result in future bookings by waitlist only.

Payment is due at the end of your appointment for any portion that may not be covered by an insurance plan.
A deposit is mandatory for dental work that requires lab service. For example; Crowns, Bridges and Appliances. No payment plans. Cash, debit, cheque, Visa and Mastercard are all accepted.

Dental plans are contracts between the insurance company, the employers and the employees. Your insurance company may qualify for Assignment Billing. As a courtesy, our office can directly bill your insurance company and will only charge you the estimated difference of the patients’ portion. Any shortfalls are 100% responsibility of the patient. We ask that patients return insurance claim forms promptly with required signatures so that we can submit to insurance companies in a timely manner. Any delay in receiving insurance claim forms will result in Non-Assignment Billing. We do our best to find out any details we can with regards to your plan: however due to the Privacy Act, most insurance companies deny dental offices from seeking patient’s insurance information. Therefore, as the patient, you are responsible to inform us of any changes to your plan as well as the details of your coverage. For example, not all insurance policies will cover the full cost for white fillings on molar teeth.

We take no responsibility for any fees that are not covered by your plan.

Information collected on our Patient Information and Medical History forms are used to provide patient centered dental care. If you have any questions about collection, use, or disclosure about this information please speak with our receptionist.

New Patient Form