• Doctor & Patient Commitment

    Doctor & Patient Commitment

    Advanced Dental Arts

  • Welcome to Advanced Dental Arts!

    Thank you for allowing us to be your trusted oral health providers!  Our practice is dedicated to providing the highest quality dental care to you and your loved ones. 

  • Appointment Policy

  • Our Goal is to provide quality dental care to all our patients in a timely manner.  No-shows, late arrivals, and last minute cancellations not only inconvenience our providers, but our other patients as well. 


    If a cancellation is necessary, we do require you to contact us at least 2 business days in advance.  Appointments are in high demand and your advanced notice will allow another patient access to that appointment time.  


    An appointment cancellation is considered last minute when the appointment is cancelled less than two business days prior to the scheduled appointment time.  A no-show is when the appointment is missed without timely cancellation notice.  In either case, a $50 missed appointment fee will apply.

  • Consent for Treatment

  • To the best of my knowledge, all the preceding answers and information provided are true, complete and accurate. It is my responsibility to inform ADA of any changes to my medical status or contact information. I authorize ADA to perform any necessary dental services that I may need during diagnosis and treatment with my written or verbal informed consent.

  • Consent to Financial Commitment

  • Direct Billing Insurance

  • Your dental insurance remains an agreement between you and your insurance company, and we will be happy to assist in preparing and submitting any necessary claim documents.  Further, we will strive to provide estimates for all future treatment, if possible.  Full payment to ADA remains your responsibility, regardless of how much your insurance does or does not pay.  


    As a courtesy, ADA will direct bill to my insurance.  In doing so, ADA does not accept responsibility for any uncovered amounts, amounts over benefit maximums, limitations, plan restrictions, etc.  I understand that ADA collects my dental coverage information only as a guideline to assist me in maximizing my benefits.  


    ADA advises me to contact my plan administrator or insurance company for questions regarding eligible procedures and authorization of treatment. In addition, I am advised to make myself aware of all costs involved with my dental care. ADA advises me to keep track of my yearly maximums, limitations, appointment dates, and accumulated amounts used on my dental benefit plan.  


    Payment is due at the time of service. I am aware that if the Advanced Dental Arts does not receive confirmation from my insurance for their exact payment, then I will be provided an estimate for my portion at the time of visit. A statement of any unforeseen balance will be provided to me.  


    I understand that a valid credit card on file is required if I wish to have my services billed directly to my dental insurance, payable to ADA.  I authorize Advanced Dental Arts to apply any balance owing under $100.00 to be automatically debited from my credit card.  For amounts owing over $100.00, ADA will contact me for payment arrangement. 

  • Card Number:   *   
    Exp:   *   CVV: *
    Name as it appears on card: *

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  • Payment in Full

  • Payment to be received at time of completion of treatment.  ADA will also gladly prepare and submit any necessary dental claim documents on the patient's behalf, payable to the patient.

  • Name of Primary Insurance Company (if applicable): .
    Group / policy number .
    Identification number .
    Policy holder name . Policy holder DOB: .

  • Name of Secondary Insurance Company(if applicable): .
    Group / policy number .
    Identification number .
    Policy holder name . Policy holder DOB: .

  • Prepayment Discount

  • ADA appreciates our patients needs to have quality dental work completed in a timely manner and understands that costs may be a deterring factor. We are glad to be able to provide our patients 3% off their total treatment bill (excluding lab & expenses) when payment is received in full at the time of booking treatment! ADA will also gladly prepare and submit any necessary dental claim documents on the patient's behalf, payable to the patient.

  • Payment Plans

  • Payment plans are available to patients on a case-by-case basis. Please let us know if you require any payment arrangements.

  • Balances Owing Over 90 Days

  • Balances owing over 90 days outside of agreement with Advanced Dental Arts are subject to third-party collections.

  • X-Rays

  • I understand my x-rays must be forwarded to Advanced Dental Arts prior to my appoinment or new x-rays may be requested by my dental provider. 

     

    X-rays may be emailed to: info@advanceddentalarts.ca

  • PHIA Consent

  • PHIA permits us to collect and use your personal health information. In certain circumstances, PHIA also allows us to share it with others both inside and outside our organization.
    We do this for purposes such as:
    To provide you with health care;
    To get payment for your care which could include private insurers;
    To do health system planning and research;
    To report as required by law;
    Unless you tell us not to, we can share your personal health information with any health care provider who has, is or will be providing you with health care. Members of your health care team are only allowed access to the information they need to give you the care you need. If you tell us not to share your information with a health care provider, we will not share your information unless permitted to required by law to do so. Please tell a member of your health care team if you do not want your information shared with a health care provider.

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