Welcome to Cabbagetown Dental Centre

New Patient Form

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Patient Information

By checking this box, you agree to receive text messages (e.g. appointment confirmation, reminders or any other relevant information regarding appointments) from Cabbagetown Dental Centre at the cell phone number provided on this patient registration form. You can withdraw your consent at any time by calling us at 416-927-7600 or emailing us at cabbagetowndental588@gmail.com.

Insurance Information

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    Secondary Insurance Information

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      We offer direct billing to insurance companies (provided that your plan is set up for direct billing). By assigning your benefits to be payable to our practice, we may send predetermination to your insurance/s prior to the day of your appointment to ensure that you have active coverage and that proposed treatments will be covered . Otherwise, insurance payments will not be guaranteed. Please check the box that applies.

      I Provide consent.

      Dental History

      Your Smile

      Medical History

      The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality.

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      To my knowledge, the above medical and dental information is correct:

      Office Policy (Please read)

      We will help prepare insurance claim forms and assist in requesting reimbursements from insurance companies on behalf of our patients. Not all services may be covered by dental insurance and every plan has its own rules and exceptions. We will do our best to help you clarify your plan. However, it is the patient's responsibility to understand his/her own dental insurance benefits. Unless otherwise agreed upon, services are to be paid for at each visit as they are performed.

      We require a minimum of 2 business days notice (excluding Sunday) if you need to cancel or reschedule your appointment. Otherwise, this request will be subject to $75 insufficient notice fee. This applies to missed appointments as well. Such fee is the patient's responsibility as insurance will not cover a broken appointment.

      Any appointment times you are offered will not be finalized until we have confirmed with you via phone/email.

      I consent to the sharing of personal information about myself or my dependents with relevant dental/healthcare providers to facilitate treatments and with my insurance company for the purpose of processing insurance claims and the determination of benefits. I further agree to receive electronic messages in regards to communicating appointments, company news and updates which can be withdrawn at any time. I authorize the Dentists at Cabbagetown Dental Centre to perform all dental or diagnostic procedures agreed to be necessary , including x-rays, photographs, and the use of local anesthetic or other prescribed drugs as indicated.

      I agree that the typed name above will be the electronic representation of my legal signature. By signing electronically, I am certifying that I have read, understand and agree to the office policy stated in this online form.

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