Patient Forms – Enhance Dental care

Appointment Policy
All appointments are considered confirmed unless you contact our office to cancel or reschedule. It is your responsibility to remember your scheduled appointment.
To avoid a cancellation fee, we require a minimum of two full office business days' notice for any changes or cancellations. Please note: Cancellations left on voicemail will not be accepted as valid notice to cancel or reschedule.

Dental Insurance Due to the Policyholder’s Privacy Act, your insurance company may not provide our office with detailed information regarding your coverage. When we verify your insurance eligibility, we can only access the information available on the date of the call, and only if your insurance company chooses to disclose it.

Because of plan-specific limitations and frequency clauses, we may not be able to determine whether all recommended treatment is covered. In the event your insurance provider does not pay for services rendered, you are responsible for payment in full and must seek reimbursement directly from your insurance provider.

For detailed information about your plan, please contact your insurance company or plan administrator directly.

Policy on Amalgam (Silver) vs. Composite (White) Fillings Some insurance plans do not cover composite (white) fillings on permanent molars. In such cases, your plan may only pay the equivalent cost of an amalgam (silver) filling.

Composite fillings typically incur an additional cost between $40.00 and $160.00 per tooth, depending on the size and location of the restoration.

Please note: Our office does not provide amalgam (mercury) fillings. If you wish to receive this type of filling, we can provide you with contact information for the BC Dental Association, who may be able to refer you to a dentist that offers amalgam fillings. However, we cannot guarantee availability.

Electronic Billing Authorization By receiving treatment at our office, you authorize us to submit your dental claims to your insurance company electronically.

Patient Responsibilities

Notify us promptly of any changes to your medical history, allergies, address, phone number, or dental insurance plan.

Understand that dental treatment may not be fully covered by your plan and may exceed your policy limits.

You are financially responsible for all treatment provided.

Payment for any uncovered services is due at the time of treatment, unless a prior payment arrangement has been made with the dentist.

Consent

I have read and fully understand the above office policy regarding my dental insurance & my patient responsibility.

Today's Date (MM/DD/YYYY)

Patient Full Name

Primary applicant please sign inside the box

Personal Information

First Name

Last Name

Middle Initial

Is this your legal name?

Yes No

Birth Date (DD/MM/YYYY)*

Sex

Male Female

Street Address

City

Province

E-mail

Primary Phone Number

Secondary Phone Number

Job Title/Occupation

Current Employer/Company

Referred to clinic by (please check one):

Family/Frields Website Family Dentist Others

If Other

Name of referral:

Other family members seen here:

In Case Of Emergency

Name of next of kin or friend:

Relationship to patient:

Home phone no.:

Consent

I certify that I have read and understand the above information to the best of my knowledge. The above questions and the health questionnaire have been accurately answered.I understand that providing incorrect information cans be dangerous to my health. I authorize the dentist too release any information including the diagnosis and the records of any treatment or examination rendered to me/or my child during the period of such dental care to third party payors and/or Health practitioners. I understand that my dental insurance carrier may pay less than the actual bill for services. I understand that I am financially responsible to my dentist for the entire treatment rendered on my behalf or my dependents.

Today's Date (DD/MM/YYYY)

Primary applicant please sign inside the box

Health Questionnaire

First Name

Last Name

Middle Initial

Date of Birth (DD/MM/YYYY)

Best Contact #:

E-mail Address:

Have you been examined and /or treated by a physician within the last year?

If yes, When?

Physician’s Name:

Physician’s Phone:

Have you ever been seriously ill or hospitalized?

Yes NO

If yes, When?

Do you require any antibiotic coverage before any dental treatment?

Yes NO

Are you on blood thinners?

Yes NO

If YES the medication you are taking:

Please check (√) if you have ever had any of the following:

Blood Pressure Problems

Yes NO

Type

High Low

Diabetes

Yes NO

Type

Type 1 Type 2

Liver disease/ Hepatitis:

Yes NO

Type

Do You Smoke?

Yes NO

Other (Not listed)

WOMAN ONLY: Are you pregnant?

Yes NO

*MEDICATIONS you are taking?

Is there anything else concerning your health not listed that you think the doctor should know about?

Yes NO

Move Duplicate Settings Delete When was your last dental visit?

Have you had x-ray taken with in the last year?

Are you having dental discomfort or dental pain?

Have you ever experienced abnormal bleeding associated with previous extraction, surgery or trauma?

Yes NO

How many times do you brush a day?

How many times do you floss a day?

Do your gums bleed when brush or floss?

Never Sometimes Often

Do you have any oral habits: clenching, grinding, nail biting, thumb sucking?

Yes No

Have you ever had professional tooth brushing & flossing instructions?

Yes No

I am interested in dental sedation.

Yes No

Have you had and problems with or unpleasant reactions to dental treatment?

Yes No

Are you happy with the appearance of your teeth?

Yes No

My primary concerns is:

Today's Date (DD/MM/YYYY)

Primary applicant please sign inside the box

Patient registration Forms

Personal Information

In Case Of Emergency

Health Questionnaire

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