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  • New Patient Registration Information

    Please complete the form below
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  • Work Information

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  • Guarantor/Insurance Policy Holder

    Person Responsible for Account
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  • Dental Health Questionaire

    We believe that each patient deserves to know what their level of dental health is, how they got there, and what treatment options are available to help them reach the level of health they deserve. This begins with the careful diagnosis and a personalized treatment plan. We will perform a comprehensive oral examination of your teeth, gums, jaw joints, bite, and soft tissues. We will also take appropriate x-rays, and when beneficial we may take additional diagnostic records such as photographs or casts of your teeth to further evaluate areas of concern. Once all your records have been completed, they will be carefully evaluated and we will review our findings with you and discuss treatment options. A personalized treatment plan will then be developed to help you achieve the goals we set together.
  • Please help us better understand your dental health needs and goals by answering all of the following questions:
  • Medical History

    Please complete the following information to the best of your knowledge.
  • APPOINTMENTS

    We value your time so you can expect us to see you at the appointed time and to keep your time spent in our office as short as possible. In return, when you make an appointment with us, please be on time as we have reserved our time just for you. Please make every effort not to change your scheduled appointment. If you must change an appointment, please provide us at least 24-hours advanced notification so that we may use our time to accommodate other patients. Broken and missed appointments create scheduling problems for other patients and our practice. If you are more than 10 minutes late for your appointment, you may be asked reschedule. We value your time, so we ask that you please value ours as well.
  • FINANCIAL POLICY

    Unless another financial option is PRE-ARRANGED, payment is due the day of treatment, or on pre-op visits for sedation appointments. Should a patient have dental insurance with assignment to Dr. Cansler, the estimated patient portion will be the amount due. Insurance payments without assignment will be sent to the insured with payment due in full. Payment Options: For your convenience we accept cash, check, Visa, MasterCard, and Discover. We do not currently accept American Express, CareCredit, or LendingClub. For Patients with Dental Insurance: Dental insurance plans often pay less than the actual fee for service, therefore the patient or guarantor is the responsible party for all the dental services provided. Dental insurance in most cases is a benefit with limitations and should not be expected to take care of all costs. Your dental benefits and how they relate to your specific needs will be estimated and explained to you during the treatment discussion appointment. MEDICARE: Dr. Cansler does not participate with ANY Medicare plans and is considered "Opted Out". Medicare does not pay for any covered items or services you get from an opted out doctor or other provider, except in the case of an emergency or urgent need. Payment will be due at the time of service. We are happy to provide an itemized receipt to you if you choose to attempt to seek reimbursment from Medicare directly. MEDICARE: Dr. Cansler does not participate with ANY Medicare plans and is considered "Opted Out". Medicare does not pay for any covered items or services you get from an opted out doctor or other provider, except in the case of an emergency or urgent need. Payment will be due at the time of service. We are happy to provide an itemized receipt to you if you choose to attempt to seek reimbursment from Medicare directly.
  • AUTHORIZATION AND CONSENT

    General Consent to Treatment: I agree and consent to a dental examination by Dr. Cansler. I understand that additional diagnostic procedures and dental treatment may be recommended and will be discussed with me prior to being done. Also, I acknowledge that there are no guarantees, expressed or implied, as to the results of any procedures or dental treatment performed. Release of Information: I authorize Dr. Cansler to release an information regarding my dental/medical history, diagnosis or treatment to third party payors and/or other health professionals. Assignment of Insurance Benefits: I authorize and request my insurance company to pay my benefits directly to Dr. Cansler. Photography Release: I authorize Dr. Cansler to take photographs of me to help me better understand my current dental condition and possible treatment options. I understand and will comply with Appointment Policy. I understand and comply with the office Financial Policy. I understand and agree to the General Consent for Treatment.
  • NOTICE OF PRIVACY FOR PROTECTED HEALTH INFORMATION

    I hereby acknowledge that I have reviewed Cansler Dental’s Notice of Privacy Practices. I understand that I may ask any questions I might have regarding this notice.
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