General Consent for Dental Treatment

I authorize the dentist to perform all diagnostic procedures including and not limited to x-rays and photographs, as may be required to determine necessary treatment, and to perform necessary or advisable treatment.

Personal Information

I understand that the collection of my personal information is necessary for the following purposes:

Opening and updating patient files
To invoice patients for dental services, process credit card payments, collect unpaid payments
Process claims for payment from third party insurance/benefits providers
Contact me with regards to treatment, appointments and news regarding our practice
Providing proper and safe dental treatment with respects to my medical health which may include providing information to other dental specialists or medical providers
I understand that Glenbrook Dental will collect, use and disclose this information in accordance with the Law under the Canadian Personal Privacy Act as well as the regulations outlined by the Alberta Dental Association and College. By signing this, I consent to the collection, use and disclosure of my personal information for the reasons outlined above.

Cancellation Policy

We understand that sometimes you need to reschedule your appointment and ask that you provide us with notice 2 business days prior to your appointment. By signing this, I understand that if insufficient notice is given, a fee may be applied.

Insurance and Billing

We extend the courtesy of sending your insurance claims electronically. Due to the Canadian Personal Privacy Act, the details of your dental plan are kept confidential therefore we cannot access this information.

I understand that I am responsible for knowing the details of my dental plan including annual plan maximums, frequencies and all other limitations. If you have any questions regarding your insurance plan, please ask our administrative staff and we would be more than happy with assist you.

I have read and understand all of the above policies and have provided accurate information to the best of my knowledge.