CONFIDENTIAL PATIENT RECORD, CANCELLATION AND RECORDS RELEASE

CONFIDENTIAL PATIENT RECORD
NAME:
DATE OF BIRTH:

Month Day Year
Date
Home Address

ADDRESS

Street Address Line 2

CITY

POSTAL CODE
Phone Number Home
Please enter a valid phone number.
Phone Number Cell
Please enter a valid phone number.
Phone Number Work
Please enter a valid phone number.
EMAIL:
example@example.com
PREFERED CONTACT METHOD
REFERRED BY:
PHYSICIAN:
IN CASE OF EMERGENCY, CALL
Phone Number Work
Please enter a valid phone number.
PRIMARY INSURANCE
PRIMARY CARRIER
EMPLOYER:
POLICY:
ID:
POLICY HOLDER:
DATE OF BIRTH OF PRIMARY POLICY HOLDER

Month Day Year
Date
SECONDARY INSURANCE - IF APPLICABLE
SECONDARY CARRIER:
EMPLOYER:
POLICY
ID
POLICY HOLDER:
DATE OF BIRTH OF SECONDARY POLICY HOLDER

Month Day Year
Date
FOR UNDER 15 YEARS OF AGE PATIENTS
CHILD #1 - NAME
CHILD #1 - HEALTH CARD #
CHILD #2 - NAME
CHILD #2 - HEALTH CARD #
CHILD #3 - NAME
CHILD #3 - HEALTH CARD #
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.
Patient (Parent/Guardian) Signature: (please write your signature with your mouse on a pc or your finger on a phone or tablet)

Clear
Date

Month Day Year
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.
Patient (Parent/Guardian) Signature:

Clear
Date

Month Day Year
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.
Patient (Parent/Guardian) Signature

Clear
Date

Month Day Year
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.
Previous Dental Practice:
(Patient's Name)
Date:

Month Day Year
Date
Patient/Parent or Guardian Signature:

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.
Name
Signature:

Clear
Date

Month Day Year
Date
Should be Empty:

CONFIDENTIAL PATIENT RECORD

PRIMARY INSURANCE

SECONDARY INSURANCE - IF APPLICABLE

FOR UNDER 15 YEARS OF AGE PATIENTS

EDI SIGNATURE AND ASSIGNED SIGNATURE:

PATIENT CONSENT

CONSENT TO TRANSFER PATIENTS RECORDS

FEES AND CANCELLATION POLICY