Medical History Questionnaire
IN CASE OF EMERGENCY,WE SHOULD NOTIFY
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. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
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— We are happy to complete insurance forms relative to your dental treatment.
— We do not accept assignment.
— This simply means that your insurance cheque will go directly to you, not to this office.
— It is important to understand your insurance is an agreement between you and your insurance company.
— herefore, you are directly responsible for the payment of fees.
— As a courtesy to our patients our staff will complete any forms to help you collect from your insurance company.
— Each patient will receive an insurance form for each appointment. It should be completed, signed and forwarded to your plan administrator or insurance company.
— They will reimburse you directly to the extent of your coverage.
— If we can be of further assistance, please do not hesitate to call.
— Please be advised that when you are unable to attend a scheduled appointment, 48 hours notice of cancellation is requested. Failure to do so may result in a full charge for the scheduled appointment. Please remember that someone else maybe able to use the appointment that you are missing.
— In order to protect your privacy, we are required by law, as of January 1, 2004 to let you know how this office will collect, use and disclose information about you
- To deliver safe and efficient patient care
- To identify and ensure continuous high quality service
- To assess your health needs
- To advise you of your treatment options
- To enable us to contact you
- To establish and maintain communication with you
- To offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care generally
- To communicate with other treating health-care providers, including specialists and general dentists who are the referring dentists and /or peripheral dentists
- To allow us to maintain communication and contact with you to distribute health-care information and to book and confirm appointments
- To allow us to efficiently follow-up for treatment, care and billing
- For teaching and demonstrating purposes on an anonymous basis