Your Trusted Dental Clinic in Mississauga for Professional Dental Cleaning

1. PERSONAL INFORMATION

Name:

Address:

Telephone:

Physician:

2. MEDICAL HISTORY

The following information is required by the dentist to assist in proper diagnosis and treatment. AlI information is confidential.

Specify:

3. DENTAL HISTORY

PATIENT CERTIFICATION AND APPROVAL

I, the undersigned, certify that all of the above medical and dental information is true to my knowledge and I have not omitted any pertinent information.

PATIENT (GUARDIAN) CONSENT (FOR MINORS)

I, the undersigned, consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetic as indicated, and I will assume or includingioring of dental and orai surgery procedures agreed to responsibility for fees associated with these procedures.

Dr Glenn S. McKay Rockwood Dental Group

22B-4141 Dixie Rd Mississauga ON L4W 1V5 905 624 8917

This office operates on the Current ODA fee Guide for Most dental procedures.

Because insurance companies/policies change so often it is your responsibility to be aware of plan maximums and what your plan covers. We can send estimates to insurance companies for you however, We provide dental services you require not what your plan covers.

Any Balance or non payment from the insurance company is your responsibility.

I know that your office has a Privacy Code, and i can ask to see the Code at any time.

I agree that Rockwood Dental Group can collect, use and disclose personal information to specialists and insurance companies about me/my dependant as set out in the PIPEDA.

Insurance & Payment Policy

At Rockwood dental Group, we make every effort to aid you in collecting the maximum benefit payable from your insurance company. Please review our insurance and payment policy.

Payment Options:

Our mission is to provide excellence in dentistry that meets your individual needs. In order to reduce the cost of providing dentistry to our patients, payment is expected at the time of service.

We are pleased to offer the following payment options:

Payment is made in full by cash, interact, Visa, or MasterCard with non-assignment of your dental benefits. We will process your dental insurance claim for you and have the insurance cheque sent directly to you within 3-5 business days.

We will accept assignment of your primary dental benefits and collect the co-payment at the time of service. We will provide you with a copy of any secondary insurance claims for you to submit. A credit card will be kept on file to process any payment not reimbursed to us within 30 days and a receipt of any charges will be mailed to you. I hereby assign payment of my dental benefits directly to Rockwood Dental Group. I hereby authorize Rockwood Dental Group to process payment to my credit card of any outstanding balance occurred during the course of dental treatment to keep my account current within 30 days.