Please feel free to ask our team for help in completing this form if required.

    NAMES AND ADDRESSES OF PARENTS OR GUARDIANS (If Necessary)

    PERSONAL INFORMATION OF PATIENT

    INSURANCE INFORMATION

    MEDICAL INFORMATION


    DENTAL HISTORY


    CHECK IF YES


    Medical History Questionnaire

    The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.






    WELCOME SMILE OFFICE POLICIES

    At Welcome Smile Dental your oral health is our main priority. In order to better serve you, and to ensure there is no interruption in your dental care, it is important for all our new patients at the practice to review and understand our office policies as set out below.

    FINANCIAL POLICY

    Payment of fees must be made at the time services are rendered. For your convenience, we accept cash, Visa, MasterCard, debit & certified cheques. Please note that NSF cheques will be subject to a $25 additional charge to cover administrative and bank charges.

    Please be aware that your dental insurance is a contract between you and your employer. It is your responsibility to understand your benefits and dental coverage. However, as a privilege to patients with dental insurance, we will gladly submit your insurance claims electronically to expedite the reimbursement of benefits directly to you from your insurance company. In order to keep your insurance information up-to-date, you must provide our office with all pertinent information relating to your insurance coverage.

    Upon request, a written estimate can be provided to you for all treatment planned procedures. If you are uncertain about your dental insurance coverage, our office can send a pre-determination of benefits directly to your insurance company before any services are provided. The pre-determination is non-binding and you are under no obligation to continue with any such treatment.

    Should you require special financial arrangements, these must be discussed and arranged in writing in advance of entering into any major treatment. For more involved, complex or extended treatment, a non-refundable deposit may be required prior to the start of your treatment. This deposit will be applied towards your final balance owing.

    Please do not hesitate to ask about the estimated cost of your treatment.
    It is your right to understand our fees.


    CANCELLATIONS & MISSED APPOINTMENTS

    When you book an appointment with us, we reserve that time specifically for you to see the dentist or hygienist. As such, we require 2 business notice in the event an appointment must be cancelled. This allows other patients awaiting treatment to be rescheduled into the time slot initially reserved for you. Short notice cancellations (i.e. less than 2 business days notice) and missed appointments are subject to a $100.00 fee per 60 minutes of scheduled time.

    AGREEMENTS & SIGNATURE