www.burloakcentredentistry.com - Patient Registration Form Logo

  • Patient Registration Form

  • How did you hear about us?

  • Emergency Contact

    In case of an emergency, who should we call?

  • Financial Responsibility

    If you are under the age of 18, please indicate the following:

  • Telephone numbers

  • Insurance Coverage

  • Primary Insurance

  • Secondary Insurance

  • Appointment Cancellations

  • Cancellation Charges: I understand that when an appointment is booked for me, the staff time is reserved for me. The equipment and materials are set up for me. If I need to change or cancel an appointment, I will provide 2 business day’s notice (except in emergency situations). I understand that without 2 business day’s notice, a charge may be applied. The amount charged will depend on the length of the appointment.

  • Medical History

    Do you currently have, (or within the last 6 months, had) any of the following?

  • Women Only

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  • Dental History & Concerns

    Mark the areas that apply, and if desired, use the lines to provide additional details

  • Sign below to confirm that all the information on this registration form is accurate to the best of your knowledge.

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  • Insurance & Payment Policy

    At Burloak Centre Dentistry, we make every effort to aid you in collecting the maximum benefit payable from yourinsurance company. Please review our insurance and payment policy.

  • Payment Options

  • Our mission is to provide excellence in dentistry that meets your individual needs. In order to reduce the cost of providing dentistry to our patients, payment is expected at the time of service.

    We are pleased to offer the following payment options:

  • Payment is made in full by cash, interact, Visa, or MasterCard with non-assignment of your dental benefits. We will process your dental insurance claim for you and have the insurance cheque sent directly to you within 3-5 business days.

  • We will accept assignment of your primary dental benefits and collect the co-payment at the time of service. We will provide you with a copy of any secondary insurance claims for you to submit. A credit card will be kept on file to process any payment not reimbursed to us within 30 days and a receipt of any charges will be mailed to you.

  • I hereby assign payment of my dental benefits directly to Burloak Centre Dentistry.

    I hereby authorize Burloak Centre Dentistry to process payment to my credit card of any outstanding balance occurred during the course of dental treatment to keep my account current within 30 days.

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