• CONFIDENTIAL PATIENT RECORD

  •  /  /
    Pick a Date
  • PRIMARY INSURANCE

  •  -  -
    Pick a Date
  • SECONDARY INSURANCE - IF APPLICABLE

  •  -  -
    Pick a Date
  • FOR UNDER 15 YEARS OF AGE PATIENTS

  • EDI SIGNATURE AND ASSIGNED SIGNATURE:

    I hereby assign my benefits; payable from claims submitted electronically to my dentist  and authorized payment directly to him/her. This authorization shall continue in effect until the undersigned revokes the same.
  • Clear
  •  /  /
    Pick a Date
  • I authorize release, to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named dentist. The authorization shall continue in effect until the undersigned revokes the same.

  • Clear
  •  /  /
    Pick a Date
  • PATIENT CONSENT

    I, the undersigned, certify that the medical and dental information I provide is true to my knowledge and I have not omitted any pertinent information. I consent to the preforming of dental procedure agreed to be necessary or advisable, including the use of local anesthetic as indicated, and I will assume responsibility for fees associated with these procedures.
  • Clear
  •  /  /
    Pick a Date
  • CONSENT TO TRANSFER PATIENTS RECORDS

    By signing below - I hereby request and  authorize the release of my dental records to Hammond Dental Centre.Complete dental records including patient chart, radiographs, models, photographs, and any other documentation including referral letters and correspondence with specialists and / or insurance companies.Please mail records or email, if electronic files, to the address or email listed above. I understand that only copies of my records and duplicates of my radiographs and models will be provided, and that if no duplicates can be made, that the originals will be forwarded to the address listed in the letterhead and returned to the sending dentist. I agree to pay any fees that may occur in the transferring of my records, including the duplication of radiographs and models if necessary.
  •  /  /
    Pick a Date
  • Clear
  • FEES AND CANCELLATION POLICY

    We try earnestly to offer friendly and timely service that accommodates your needs, and to continue to maintain this effort our practice requires a minimum of two business days’ notice to change or cancel a reserved appointment, or a rescheduling fee will apply.This appointment time has been reserved specifically for you, when an appointment is missed it not only affects the doctor or hygienists, it affects the patient who has been waiting for an appointment time.While we make every effort to contact patients in the days preceding their appointments, this confirmation is a courtesy and does not eliminate the responsibility of the patient to attend their scheduled appointments.If you need to change/ cancel an appointment, please call and speak with one of our staff members, or leave us a message on our voicemail at 902-835-1031Please understand this policy benefits everyone. Help us be available for you!I have read and understand the Fees and Cancellation Policy.
  • Clear
  •  /  /
    Pick a Date
  •  
  • Should be Empty: