Innovation Drive Dental Form

FINANCIAL / INSURANCE INFORMATION

At Innovation Drive Dental payment is due when services are rendered. If you have dental insurance we will submit the claim on your behalf and accept reimbursement from your insurance directly according to your policy specifications. Our office policy requires any insurance differences or services not covered to be paid by the patient on the day of the appointment. Our fees are based on the ODA Fee Guide for the current year. We accept Visa, MasterCard, Debit, Cheques and Cash. If you have any questions regarding our fees, please inquire.

Person responsible for your account:

Subscriber - Subscriber:

Date of Birth - Date of Birth:

Insurance Co - Insurance Co:

Policy # - Policy #:

ID # - ID #:

Employer - Employer:

Secondary dental insurance

Subscriber - Subscriber:

Date of Birth - Date of Birth:

Insurance Co - Insurance Co:

Policy # - Policy #:

ID # - ID #:

Employer - Employer:

I the undersigned, state that I have completed all information forms accurately, without knowingly omitting information. On the basis of confidentiality, I herby consent to the release and transfer of any patient information and dental records within my file for dental insurance purposes or inter-practitioner communication. I agree that Innovation Drive Dental has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. Please note that personal information used, disclosed, secured or retained by Innovation Drive Dental will be solely for the purposes for which we collected it and in accordance with the National Privacy Principles contained in the Personal Information Protection and Electronic Documents Act.

I agree that the electronic signature above will be an electronic representation of my signature for all purposes, just the same as pen-and-paper signature.

Please check any of the following that may apply to you:

Are you currently under the care of a physician? Yes No

For what condition? - For what condition?

Name - Name

Phone Number - Phone Number

Health Card # (For Prescription Purposes)

Are you currently taking any prescription medications? Yes No

Have you ever had complications following medical treatment? Yes No
Dental Treatment? Yes No

Weight - Weight

Blood Pressure - Blood Pressure

On a scale of 1-10, how important is your dental health? (1=not important; 10=very important)

When was your last dental visit? - When was your last dental visit?

When was your last oral cancer screening? - When was your last oral cancer screening?

When was your last complete set of x-rays? (approx 18 x-rays) - When was your last complete set of x-rays? (approx 18 x-rays)

What is the most important thing to you about your dental visit today? - What is the most important thing to you about your dental visit today?

If you could change anything about your mouth, teeth or smile what would it be? - If you could change anything about your mouth, teeth or smile what would it be?

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 understand that I am financially responsible for services rendered to me or to my dependents that are not fully covered by my insurance (if applicable) and I may be billed for this remaining balance. I agree to pay all uninsured services or insurance differences at the time services are performed, unless other arrangements are made.

PERSONAL INFORMATION

FINANCIAL / INSURANCE INFORMATION

Thank you.