SCHEDULE YOUR APPOINTMENT

1

Have you been to Greenwoods Dental Centre?* This field is required.

NEW PATIENTEXISTING PATIENT

2

Which Greenwoods Dental Centre location are you booking for?* This field is required.

693 MCPHILLIPS STREET

249 ½ HENDERSON HIGHWAY

246 PORTAGE AVENUE

1531 PEMBINA HIGHWAY

1462 REGENT AVENUE WEST

WILL DISCUSS LATER

3

Your Information

NAME

DATE OF BIRTH

EMAIL ADDRESS

PHONE NUMBER

ADDRESS

4

What is the reason for your appointment?

ie. Tooth Ache, Fillings, Root Canal, Implants, Cleaning

5

Requested Appointment Date & TimePlease note that your appointment may be subject to change. We will contact you in regards to any adjustments.

6

Are you covered by dental insurance?* This field is required.

YESNO

7

Which dental insurance are you covered by?

Private Insurance Company (ie. Canada Life, Manitoba Blue Cross, Manulife, etc)

Non-Insured Health Benefits (NIHB / Treaty)

Social Allowance Health Services (SAHS)

Other (ie. MPI, WCB, etc.)

8

Your Private Insurance InformationInsurance information not provided by the patient prior to a weekend appointment, are at a higher risk of having to pay for the appointment at the time of treatment. This is because we are unable to verify insurance coverage as the insurance offices are closed on Saturday and Sunday.

INSURANCE COMPANY NAME

INSURANCE HOLDERS' NAME

INSURANCE HOLDERS' DATE OF BIRTH

GROUP / PLAN / POLICY #

ID / CERTIFICATE #

9

Do you have dental coverage through a secondary Private Insurance Company?* This field is required.

YESNO

10

Your Second Private Insurance InformationInsurance information not provided by the patient prior to a weekend appointment, are at a higher risk of having to pay for the appointment at the time of treatment. This is because we are unable to verify insurance coverage as the insurance offices are closed on Saturday and Sunday.

INSURANCE COMPANY NAME

INSURANCE HOLDERS' NAME

INSURANCE HOLDERS' DATE OF BIRTH

GROUP / PLAN / POLICY #

ID / CERTIFICATE #

11

What is your Status Number?Please enter your ten digit status / treaty number.

First three numbers: Band # . . . Next five numbers: Family # . . . Last two numbers: Position #

12

Due to conflicting office hours, patients covered by SAHS can only make appointments from 8:30am until 3:30pm every Monday - Friday.

13

What is your SAHS Case Number?Please enter your six digit case number.

14

Other Insurance: Please ExplainPlease enter detail about your insurance and we will contact you to discuss further.

15

Please note that you will be paying for any treatment at the time of the appointment.

A $100 deposit must be submitted prior to the appointment which can be done in-office or online. There will be a 3% surcharge for any charges made with credit card(s).

16

Additional Notes / Informationie. parent/guardian name and date of birth, additional family members names and date of births to add to profile

17

GWD Appointment RequestGWD Appointment Request

GWD Appointment Request