• In order to effectively serve you, please fill out the information below as completely and accurately as possible. You will be prompted to e-sign at the end of the form. All information is strictly confidential. 

  • PERSONAL INFORMATION


  • You have indicated that you are not personally responsible for your financial account. It is important that the person who is responsible provides us with a signed copy of the Blueridge Dental Financial Agreement prior to your first/next visit. 

    Please have them fill in their information and read and sign the Financial Agreement below before proceeding.

  • You have indicated that you are not personally responsible for your financial account. It is important that the person who is responsible provides us with a signed copy of the Blueridge Dental Financial Agreement prior to your first/next visit.

    Please fill in the responsible person’s information below and we will contact them regarding the Blueridge Dental Financial Agreement.

  • Financially Responsible Person’s Information:

  • FINANCIAL AGREEMENT

  • Your dental insurance is an agreement between you, your employer and the insuring company. We are happy to bill your insurance company directly whenever possible. Please be aware that:

    1. You are fully responsible for all fees associated with your dental treatment.

    2. You are responsible to know your insurance: what’s covered, deductible amounts, limits, etc.

    3. Notify us of any changes to your dental insurance.

    4. You consent and authorize Blueridge Dental to submit claims electronically to your insurance company, to contact your insurance company for any information required related to claims, payment, coverage, eligibility, etc.

    5. You must pay your estimated portion of the fees, when required at each appointment.

    6. All major procedures (e.g. crown, bridge, implants, etc.) will be non assignment. We will submit these claims to your insurance on your behalf. Any reimbursement will be sent to the subscriber. Full payment is required at time of service.   

    7. Any fees not covered by your insurance will be your responsibility. (Most insurance carriers do not pay 100% of the treatment costs for a variety of reasons.)

    8. We will allow 3 months from your appointment to receive payment from your insurance company. If payment is not received after this time, you will be responsible to pay the full amount.


    Our office will submit insurance claims on your behalf to your insurance company for any contribution they may provide for your treatment. Please note that once your insurance carrier has paid their portion, or after 3 months post-treatment has elapsed, any remaining balance is your responsibility.

    In an effort to limit person to person contact in our front office environment, and to keep accounts current, we are asking patients to leave a credit card on file. The credit card will be used to cover your patient portion due at time of service. Once payment is received from your insurance, any remaining balance on your account will be promptly charged to your credit card. We will notify you by email or text two business days before applying this charge.


    * For security purposes, we do not collect any credit card information on this form. We will request this information when scheduling your appointment or at first visit.

  • I, the undersigned, certify that I have read, understood and agree to Blueridge Dental's Financial Agreement.

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  • INSURANCE INFORMATION

  • Primary Policy Holder's Information:

  • Secondary Policy Holder's Information:

  • APPOINTMENTS

  • It is your responsibility to be present for your appointment. We consider appointments confirmed at the time of booking. Should you need to change your appointment we require 2 full business days notice. Unless previously arranged, we do not permit appointment changes via email. We reserve the right to charge your account for missed or short notice cancelled appointments.

  • DENTAL HISTORY

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  • MEDICAL HISTORY

  • The following information is required to enable us to provide you with the best possible dental care. All information is strictly private. We will review the questions and explain any you do not understand.  Please fill in the entire form as accurately as possible.

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  • Please read the following list thoroughly and check any or all that currently or previously apply to you

  • For Women:

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  • Emergency Contact:

  • PRIVACY, DISCLOSURE & CONSENT

    • Click here to read details  
    • Blueridge Dental is committed to maintaining the privacy and security of patient information, and all collection, use and disclosure of personal information by Blueridge Dental will be carried out in compliance with the Personal Information Protection Act (“PIPA”). Blueridge Dental will collect, use and disclose your personal information for the purposes of delivering dental care and related services to you, to facilitate payment for such services, and for other purposes permitted or required by PIPA. We may also collect and share information about you with your insurance company to facilitate payment or reimbursement for services provided to you. For more information about our personal information privacy practices, ask us for a copy of our privacy policy.

      In appropriate circumstances, the dentist may refer you to a specialty dentist or another healthcare provider. If you agree that such a referral should be made, then Blueridge Dental may need to share or exchange your information with the specialty dentist/healthcare provider for the purposes of ensuring appropriate care and treatment is delivered to you. The quality and efficiency of care is improved when both the general and the specialist dentist/healthcare provider have access to the same information about you. If you do not want Blueridge Dental to exchange information about you, please ensure that you advise the dentist of your preference.


      Blueridge Dental operates on an open concept, which means it may be possible for other patients to overhear discussions taking place in the treatment area. We recognize that some patients may have concerns about their privacy. If you have such concerns, please ensure that you bring them to the attention of the staff. Private consultation space is available for patients who express a concern about their privacy. If you do not express any concerns, we will assume that you consent to the discussion of your treatment within the treatment area as described above. For more information, please ask for a copy of our privacy policy.

       

      Privacy Act and Consent to Treatment

      By signing this form, you acknowledge and agree that (i) you have read and understood the above information prior to any professional services being provided to you at Blueridge Dental; (ii) you have been provided and have read a copy of the Blueridge Dental Privacy Policy. You can withdraw your consent at any time on the understanding that withdrawing your consent to certain information handling practices may impair the ability of Blueridge Dental to provide the services you are requesting.

    • consent section ends  
    • ACKNOWLEDGEMENT REGARDING INFORMATION PROVIDED

    • I, the undersigned, certify that I have provided an accurate and complete personal and medical/dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding my medical/dental history. Should there be any changes in either my health status or any other information I have provided, I will advise Blueridge Dental. As discussed with me, I authorize the dentists, and all professional staff working under the supervision and control of the dentists, to perform diagnostic procedures that may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary and I authorize the exchange of my personal information among Blueridge Dental, my medical doctor, and another health care provider as reasonably necessary. I have been advised that Blueridge Dental maintains a Privacy Policy and have been provided with a copy and that my personal information will be collected, used and disclosed within the guidelines of the Privacy Policy. I also understand that my personal information will be retained by Blueridge Dental in accordance with their current practices, which may involve transfer and retention outside of Canada. I, the undersigned, acknowledge that Blueridge Dental are relying upon the information which I have provided being accurate and complete.

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