Patient Information

DENTAL HISTORY

Do you remember the date of last dental visit? YesUnknown

Do you remember the date of last x-ray? YesUnknown

MEDICAL HISTORY

Are you in good health now? YesNo

Have you recently, or are you presently, taking any prescriptions or non-prescription drugs including health remedies? YesNo

Have you ever been advised against taking any specific type of medication? YesNo

Check the boxes if any of the following apply to you: Do you bleed excessively from cut or injury?bruise easilyHIV positivesmokeAlcohol and/or drug dependentNone of the above apply

Women Only: Are you pregnant?Are you breastfeeding?Are you on birth control?None of the above apply

Do you currently have (or have had in the past) any disease, condition or problem not listed above? Is there anything else about your health that we should be aware of? YesNo

Personal Information Consent Form

We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances described in this form we also collect, use and disclose personal information when permitted or required by law.

We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, emails and work telephone numbers (collectively referred to as “Contact Information”). Contact Information is collected and used for the following purposes:

To open and update patient files.
To invoice patients for dental services, process credit card payments, or collect unpaid accounts.
To process claims for payment or reimbursement from third-party health benefit providers and insurance companies.
To send reminders to patients concerning the need for further dental examinations or treatment.
To send patients informational material about our dental practice.

Contact Information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment, or has asked us to submit a claim on the patient’s behalf.

Financial information may be collected in order to make arrangements for the payment of dental services.

We collect information from our patients about their health history, their family history, physical condition, and dental treatments (collectively referred to as “Medical Information”). Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.
Patients’ Medical Information is disclosed:

To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf.
To other dentists and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining the second opinion.
To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialists for treatment.
To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion.
To other health care professionals such as physicians if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment.

If we are considering selling all or part of our dental practice, qualified potential purchasers may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.

Dentists are regulated by the Alberta Dental Association and College which may inspect our records and interview staff as part of its regulatory activities in the public interest.

I consent to the collection, use and disclosure of my personal information as set out above.

Office Policies Form

Welcome to Valley Ridge Dental Centre. You have many choices when it comes to choosing a dental office, and we are glad that you have chosen us to provide you and your family with the most advance dental treatments available. Everyone at our office is committed to providing quality dental care in a comfortable environment. Please take a few minutes to familiarize yourself with our office’s financial policies.

Insurance Information: Although many dental offices are non-assignment, our office will accept direct billing of benefits from your insurance company as part of our client services.

It is important for you to understand that there may be a difference
between our fees and what your insurance company will pay for treatment and what our office charges. You are responsible for any difference in fees.

In order to provide direct billing to our patients, we will require our
patients to provide us with a credit card on file. If we cannot calculate your balance at your dental visitwith certainty, you will be required to pay a 25% deposit following your appointment with us. This may result in a small balance or credit on your account.

If a balance still remains upon receiving payment from your insurance company we will charge the remaining balance to the credit card on file and then will notify you via telephone.

Also in order to provide direct billing to our patients that have two insurances, we will require our patients to provide a credit card number on file. If a balance remains upon receiving payment from both insurance companies we will charge the balance to the credit card on file and then will notify you via telephone.

Due to high demand of prime time appointments at our office, we require a minimum of 2 business day notice if you were to change or cancel your appointment. This is valuable time that the clinic has reserved for you, with failure to provide proper notice, we will request $100 deposit to reserve another appointment, and this deposit will be refunded when you show up at your next appointment on time

We hope that your experience with us will exceed your expectations. If we can help in any way, please do not hesitate to ask.

I have read and am aware of the above policies. I understand that I am responsible for the fees associated with the services I receive. Should I choose to direct bill my insurance company, I will be responsible for payment of any unpaid balance the day of service. I consent to the collections, use, and disclosure of my personal information when permitted or required by law.

Financial Agreement

Patient Agreement

I agree to the FINANCIAL RESPONSIBILITY for the out of pocket portion and balance not covered by my insurance plan(s).

I, authorize Valley Ridge Dental Centre to keep my signature on file and to issue a credit or debit memo to my credit card account for any over and under payment once my insurance portion has been received for dental treatment I received at Valley Ridge Dental Centre. I will be notified by phone or mail if any charge or credit is in excess of $100.00

I give permission for any claim not paid by my insurance company within 60 days, to be automatically put through on my credit card. A receipt for this transaction will be mailed with a paid statement.

VisaMaster CardAmerican Express

RELEASE OF XRAYS

***Please fill out the below form if you have had xrays done at another office within the past 3 years.***

I, , give the dentists of Valley Ridge Dental Centre consent to request any applicable xrays (panorex, recent BWs and/or Pas) and have them transferred on my behalf to:

Valley Ridge Dental Centre
11245 Valley Ridge Dr NW Suite 204,

Calgary, AB T3B 5V4, Canada
[email protected]

If you have any questions, please feel free to call us at (403) 202-2266

Thank you,

Please sign your signature in this box to submit your form