The information in this questionnaire is CONFIDENTIAL and enables our office to provide the highest level of care and service possible. Please complete all forms as completely as possible. Thank you.
Do you have any of the following allergies?
Please check any of the following problems that may apply to you:
Do you have or have had any of the following?
If you could change your smile, you would...
As our new patient, we want to take the opportunity to discuss the financial options available for all your dental needs. As there are many different unique insurance policies in Ontario. Millway Dental offers assistance to all our patients in navigating coverages. For seamless processing of insurance plans and payments we offer 2 options for your convenience.
Please select one of the options below:
This option is available for both insured and non-insured patients. Payment in full will be required on the day of service unless pre-arranged payment plans have been made especially for you. Insurance claims will be submitted as payable back to you by cheque or direct deposits. This can be arranged with your insurance provider. Some insurance plans will only offer this option and with insurance details, we will be happy to verify which payment option your insurance allows.
This option will allow insurance companies to issue payment to the dental office directly. Depending on which insurance plan you or your employer has selected will determine how much “co-pay” will need to be collected on the day of service. In selecting this option, a valid credit card must be left on file to authorize unpaid amounts by the insurance to be changed.
I am aware that I am responsible for the outstanding balance on my file for dental services rendered and unpaid by my insurance policy. I am aware that in the even my payment is declined, I must take other arrangements for payment with the dental office within 2 business days. Furthermore, failure to give 48 hours notice of cancellation or rescheduling of my appointment will result in a $100 cancellation fee. Millway Dental will inform me of a missed or cancelled appointment prior to charging fee’s to my account. My signature below verifies that I consent to Millway Dental charging this card a per the arrangement outlined in this agreement. I have had the chance to ask any questions regarding the payment agreement and all options have been explained to my satisfaction.
Release of Information: I authorize Millway Dental to release and/or obtain information and/or radiographs, when required, regarding my medical/dental history friom my physician, another dental office, insurance company.
Office Policy: Your appointment time will be reserved for you. If you are unable to keep the appointment we will require 24 hours notice, otherwise it may be necessary to charge for the time lost.
Patient Release: I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I understand that responsibility for payment for the dental services provided for myself and my dependents is mine, and I will assume responsibility for fees associated with these services.