Registration Form

Step 1 of 5

  • Office Policy

  • appointments you have booked. All appointments are considered confirmed unless you have called to cancel or change your appointment. It is your responsibility to remember your scheduled appointment.

    APPOINTMENTS - A full 2 OFFICE BUSINESS DAY notice is required to change or cancel any schedule appointments. – To avoid a cancellation fee. Cancellations that are left on office voice mail will not be accepted to change your scheduled appointment.

    DENTAL INSURANCE: Your insurance company may not give our office information regarding your contract policies; this is under the Policyholder’s Privacy Act. When our office is checking your insurance eligibility, your insurance (if they disclose your insurance information to our office) is for the date we called and your insurance will give us the information they have on file. Due to limits and frequencies under your plan contract our office may not be able determine if all dental treatment may be covered under your plan contract due to this privacy act.

    If we have problems with receiving payment from your dental plan for any treatment rendered, you understand you will pay the dentist directly and get reimbursed from your dental insurance.

    Contact your insurance company or your plan benefits department if you need information regarding your policy.

    OFFICE POLICY REGARDING AMALGAM (SILVER) VS COMPOSITE (WHITE) FILLINGS:

    Composite (white) fillings on permanent molars are not covered under some plan contract. Insurance company rarely covers for composite (white) filling on back molar teeth. Your insurance plan will cover the equivalency of an amalgam (silver) filling.

    There is a cost difference for this type of restoration which varies from $40.00 to $160.00 per tooth. This is to inform every patient: Our office does not do “AMALGAM/MERCURY” fillings.

    You understand should you want to do this type of filling we will provide you a number to the BC Dental Association and if possible not guaranteed they may be able to refer to a dentist that does “amalgam/mercury” fillings.

    ELECTRONIC BILLING

    You are authorizing my dental office to send my dental claims to my insurance company electronically.

    PATIENT RESPONSIBILITY

    Inform us of medical changes, allergies, address and telephone changes and dental plan changes. Dental treatment may not be covered or may exceed your plan benefits. You understand that you are financially responsible to the dentist for the entire treatment rendered.

    Payment for any treatment not covered needs to be paid when services rendered, unless payment plan has been previously arranged by you and the dentist.