Medical History Form

For the following questions, circle yes or no, whichever applies. Your answers are for our records only and will be considered confidential. Please note that during your initial visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.

I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquirles set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his or her staff, responsible for any errors or omissions that I may have made in the completion of this form.

We are committed to protecting the privacy of our patient's personal information and to utilizing all personal information in a responsible and professional manner. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted or required by law. We collect information from our patients such as names, home and work addresses, home, work and mobile telephone numbers and email addresses. (Collectively referred to as "Contact Information".) Contact information is collected and used for the following purposes:

*To open and update patient files.
*To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts.
*To process claims to third party health benefit providers or insurance companies where the patient has submitted a claim for reimbursement or payment or has asked us to submit a claim on the patient's behalf. Financial information may be collected in order to make arrangements for the payment of dental services.
*To send reminders to patients concerning the need for further dental examination or treatment or informational material about our dental practice.

We collect information from our patients about their health history, their family health history, physical condition, and dental treatments. (Collectively referred to as "Medical Information"). Patients' Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment. Patients' Medical Information is disclosed:

* To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of dental treatment or has asked us to submit a claim on the patient's behalf.

* To other dentists and dental specialists, where we are seeking a second opinion and the patient has consented to obtaining the second opinion or to be referred by us to another dental practitioner.

* To other health care professionals such as physicians if the patient, with their consent, has been referred by us for either a second opinion or treatment.

If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal
information. Dentists are regulated by the Alberta Dental Association and College, which may inspect our records and interview our staff as part of its regulatory activities in the public interest.

I consent to the collection, use and disclosure of my personal information as set out above.

Rescheduling Policy:

Please provide us with a minimum of 2 business days' notice to reschedule an appointment.

Electronic Insurance Claims:

Insurance providers can change benefits, co-pays, and deductible fees many times throughout the year. At times, it is impossible to accurately estimate our patients' co-payment as benefit providers will not disclose their reimbursement fees until after the treatment is complete. I hereby allow Suntree Dental to submit dental claims and/or insurance estimates electronically through CDAnet on my behalf.

Account: The Patient/Guardian is responsible for all balances on account including any and all non-payment and collection fees incurred.

• Should you recelve a payment in error from your insurance provider, please contact our office as soon as possible.
• We cannot guarantee the amount the insurance company will pay. We will perform our routine billing procedures and if, for any reason, there is a portion of your insurance claim unpaid, you will be held responsible far the outstanding balance.
• Suntree Dental is unable to enter into a dispute with an insurance company. While we can work with you to clarify any confusion or answer questions, it is not something that we can take on ourselves.
• You must keep us updated on any insurance coverage changes. In the event that your insurance policy is forfeited you will be responsible to notify our office as well as to pay for the remaining balance that is uncallected from your insurance company.
• If after 6 months from the initial submission date, a payment is yet to be received, the direct billing agreement will become void. Any uncollected insurance balances will be charged to the credit card/account on file or sent to collections.

I authorize Suntree Dental to keep my signature on file and charge my credit card/account for all balances of charges not paid by my insurance.

• I hereby authorize payment directly to Suntree Dental for services rendered, otherwise payable to me.
• I authorize the release of any information in relation to my dental claims through this office.
• I acknowledge that I have read this statement and agree with the contents.
• I understand that any accounts 90 day past due are subject to collections with a 35% collections fee