(Please check all that apply, leave any that do not apply blank)
Do you have, or have you had, any of the following?
We require 48 hours notice for appointment changes. There is a charge for missed appointments and short notice cancellations. The patient portion of fees is due at the time of service. We will accept direct assignment from your insurance company but if for any reason they reject the claim or do not pay the full amount, you remain financially responsible for the balance. Claims to insurance not paid within six weeks will be billed to the patient.
This is to certify that I, the undersigned, consent to the performing of dental treatment (hygiene, restorations, etc.) when fully informed & agreed to be necessary or advisable, including the use of local anaesthetic as indicated. I fully understand the office policy and will assume responsibility for fees associated with those procedures performed. I’ve answered all of these questions above to the best of my knowledge, acknowledging that this is confidential information shared only between myself and the dental professionals at Arbutus Dental.