New Patient Intake Form

Personal Information

Insurance Information

*The above insurance information is collected to verify identify and settle any account balances that may not covered by insurance.

*The above insurance information is collected to verify identify and settle any account balances that may not covered by insurance.

Health Information

Authorization

I have read and answered the questions to the best of my knowledge and understand that I am financially responsible for all charges, whether or not paid by insurance. I agree that Sparkleen Dental can collect, use and disclose personal information about myself or my dependents as set out above in the information about the office’s privacy policies. I further agree to receive electronic messages, including text messages, in regard to communicating appointments, requests, information, products, promotions, company news and updates which can be withdrawn at any time.

Financial Policy

Our fees are based on the quality of the products and materials we use and our experience in performing your scheduled treatment. Our goal is not to let expenses prevent you from benefiting from the quality of care you desire and need. We also realize that every patient’s financial situation is different. 

Our financial policy is intended to facilitate excellent service to you while minimizing our administrative costs.

For patients who have insurance, the entire estimated patient portion is due at the time of service. Please read and be aware of your insurance benefits, exclusions and frequency limitations. Every plan is different, and changes do occur frequently. We will perform an initial insurance verification and do our best to provide you with an estimate of your Co-pay prior to whether your secondary insurance has standard coordination of benefits or not. This may limit your secondary insurance payment.

As a courtesy, we will gladly process your insurance claims and estimate the amount not covered by your insurance. All incurred charges are ultimately the responsibility of the patient, regardless of insurance coverage.

48-hour notice is required for any cancellation or rescheduled appointment; we reserve the right to charge a missed appointment fee. My signature below certifies that I have read and understand the terms of the Financial and 48-Hour cancellation policy listed above.

General Consent Statement: I certify that I have read, understood and accurately completed the personal, medical, and dental histories to the best of my knowledge and have not knowingly omitted any information. I authorize the dentist to perform necessary diagnostic procedures and treatments to achieve the proper level of dental care. I understand that I am financially responsible to the dentist for the dental services provided, even if my insurance coverage may not be all-inclusive.

I give express consent to receiving commercial electronic messages from Sparkleen Dental. I understand my contact information will be protected and used only for communicating regarding me or my dependent’s care.

I agree that Sparkleen Dental has obtained informed consent from me with respect to the collection, use and disclosure of my personal information. Upon my request, I have been provided with a copy of the Privacy Code and agree that personal information may be collected, used and disclosed as set out in the Code and is in accordance with the Personal Health Information Protection Act, 2004.

I am aware that missing an appointment or failing to give two business days’ notice for cancellation may result in a cancellation fee.

Consent to Electronic Submission of Insurance Claims: I authorize the release, to my benefits plan administrator and CDA, the information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of service described to Sparkleen Dental. This authorization shall continue until the undersigned revokes the same.