Please ensure you have been given the correct form!
This form is intended for use by adults only. If you need the form for your child/dependent, please contact the Cobourg FDC Office at 905-372-7400.
This form is not intended to be filled out by or on behalf of minors. Please correct your date of birth above or contact Frankford FDC at (613) 398-888 before continuing.
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 authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.
I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practicioners. I authorize my insurance carrier to submit payment directly to the dentist or dental practice and for it to be applied directly to any outstanding balance on my account.
I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agreeto be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).