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PERSONAL DETAILS

Your personal details. Please review them and make any necessary adjustments.

Title

First Name

Last Name

Preferred Name

Gender

Date of Birth

Address

Address 2

Province/State

City

Postal /Zip Code

Home #

Work #

Ext.

Mobile #

Other #

Preferred Phone

Email

Contact Method

Employer/School

Occupation

Are you available for short notice appointments? (Check if available)

How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.

Emergency Contact First Name

Emergency Contact Last Name

Emergency Relation

Emergency Phone #

DENTAL INFORMATION

In the following sections, please select whichever applies. Your answers are for our records only and will be kept confidential in accordance with applicable laws. Please note that during you initial visit you may be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.

MEDICAL INFORMATION

Dental professionals primarily treat the area in and around your mouth, but since your mouth is part of your body, any medication you are taking and your health History have a important relationship with your Dental Treatment. Please answer the following question.

Please go over the following section and indicate which of the following you have or have had. If you need to add any further information, please ente

CHILDREN ONLY

Please list any medical conditions or illnesses the child has recently had. This can include Measles, Strep Throat, Tonsillitis.

INSURANCE INFORMATION

Your coverage details. Please review them and make any necessary adjustments.

Primary Insurance

Subscriber Name

Relationship

Insurance Company Name

Policy #

Subscriber Date of Birth

Subscriber ID #

Div./Group Number

Employer

Additional Notes

Secondary Insurance

Subscriber Name

Relationship

Insurance Company Name

Policy #

Subscriber Date of Birth

Subscriber ID #

Div./Group Number

Employer

Additional Notes

Patient Signature

Financial Policy

At McKenzie Towne Family Dental, we are committed to providing the best possible treatment for our patients. Our fees are reasonable and competitive according to Alberta Dentists Association Standards. You are responsible for payment at the end of your dental visit regardless of your insurance company’s determination of what is usual and customary unless other arrangements have been made. As a courtesy we will be happy to file your claims with the appropriate insurance company. When possible we will use electronic submission which will speed the process for you and you should receive your insurance reimbursement within a few short days. It is your responsibility to know and understand your dental benefits. As per Canadian Privacy Act Laws, it is you, as the policy holder, who is responsible for notifying us of any changes to your coverage, as well as knowing the various procedures covered under your plan to avoid disappointments with claim reimbursements. We will do our best to assist you with your claims. When appropriate we will file for an estimation of dental benefits for a treatment plan. But please keep in mind that insurance companies do not guarantee anything over the phone or in writing, and therefore any additional costs not covered by your insurance are your responsibility. By signing I authorize “McKenzie Towne Family Dental” to send & receive claims or information to my dental insurance provider via electronic submissions, mail or fax. This is also an authorization for my dependents. I understand I am responsible for all fees for services provided the same day of service. A $25 fee will apply for any cheques returned insufficient funds from your financial institution. We confirm all pre-booked appointments two weeks in advance and appointments 2 business days in advance; please provide 2 business days’ notice of appointment cancellation to avoid a “failed appointment fee” of $100. We understand each circumstance may vary. We accept: Debit, American Express, Visa and MasterCard. Please note that we no longer accept cash payments.

Personal Information Privacy Act
We are committed to protecting the privacy of our patients’ personal information and to utilize all personal information in a responsible and professional manner and disclose personal information when permitted or required by law.

Personal Information Procedures

We collect contact, medical and financial information about our patients such as names, home/work addresses, home/work phone numbers, e-mail addresses, date of birth, insurance plan details, health/dental histories, emergency contact information.

* Contact information is disclosed to third party health benefit providers and insurance companies, with the consent of the patient, for purposes of submission of claims, for reimbursement or payment of dental care, predetermination of dental treatment, open and update patient files, invoice patients for dental services, process dental claims, and to send reminders to patients concerning the need for further dental treatment.
* Medical information is disclosed, with consent of the patient, to other dentists, dental specialists, or health care professionals such as physicians.  It is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.
* Financial information is collected for payment processing purposes.  It is not shared with third parties unless permitted by law for outstanding bill collection purposes.

In the event our dental office ever sells the practice, the new dental practitioner may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale, all personal information will be safeguarded.  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 consent to the collection, use and disclosure of my personal information as set out above and that of my dependents.

Signature of Patient or Responsible Party:

Date:

Print Patient Name(s) of all family members this applies to: