New Patient Form

Provide at least one phone number to contact you at: (Required)

Two Payment options are available - Please choose ONE only

Option 1 (Non-Assignment)

All accounts are paid at the time of service. The cheque is mailed by your insurance company, made payable to the subscriber and you may receive it in as little as 3 days.

Option 2 (Assignment)

In order for Creekside Dental Care to accept payment from your insurance, our office requires the following:

• Any portion not covered by insurance must be paid at time of service
• Valid Alberta Drivers Licence
• All accounts to be cleared within 45 days from treatment date otherwise a 15% interest charge will incur

By choosing Option 2 (Assignment), you will be asked to provide the above required information at your first dental appointment.

The insurance claim will be sent electronically. If Insurance does not provide the exact patient portion, our office will estimate your portion for the visit. Should the charge be over $200.00, our office will try to contact you prior to putting the charge through, however we are not calling for authorization but rather to make you aware of the charge. We wish to stress that the financial responsibility for services rendered rests with the patient and his/her family, regardless of any insurance coverage; your insurance policy is a contract between you and your insurance company. We cannot guarantee payment or coverage of your claim.

In the rare case that we have not received the insurance payment within 31 days, we will then contact yourself so that you may contact your insurance company to enquire about the claim. If within 45 days of your treatment our office has still not been paid, we will then inform you that your credit card will be charged the total amount owing. All collection costs will be paid for by the patient.

To the best of my knowledge, all of the preceding information I have provided is true and correct. If I ever have a change in my health, or a change in my dental coverage, I will inform the office at my next dental appointment without fail.

I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependant(s) to third-party insurance carriers, payers, and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.

I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance (if applicable), and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependants (if any).Thank you for choosing Creekside Dental Care, we look forward to taking care of your dental health.

If you have any questions regarding this agreement, please do not hesitate to bring it to our attention.