As you are aware, you are fully responsible for the payment of your dental account.
When an appointment is booked, that time is reserved exclusively for you and anyone else requesting time will be denied. For this reason, a
minimum of 2 full business days notice is required to change your appointment. Failure to provide notice will result in a minimum of a
$100 cancellation fee.
If you do not have dental insurance, you will be required to pay your account in full after each visit. If you have a dental plan, we would be happy to direct bill your insurance company on your behalf. However, your patient portion is due at the end of each appointment. If there is a balance remaining after submitting to your insurance company, this balance will be your responsibility. All overdue accounts will be subject to interest charges.
It is your responsibility to know what benefits your insurance covers, how often services can be performed, annual maximums, and percentages.
I have read the above and agree to accept responsibility for my dental account. "My dental account" is defined as any costs incurred by any and all persons or family members receiving dental treatment and or receiving benefits on the same insurance plan at any time. Should any conditions change, I agree that it is my responsibility to notify City Square Dental Center Dental Clinic of these changes before any costs are incurred.
We are committed to protecting the privacy of our patients' personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use, and disclose. In addition to the circumstances described in this form, we also collect, use, and disclose personal information when permitted or required by law.
We collect information from our patients such as names, home addresses, workaddresses, home telephone
numbers, work telephone numbers, e-mail addresses, and patient photographs (collectively referred to as "Contact Information"). Contact information is collected and used for the following purposes:
Contact information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient's behalf.
Financial information may be collected in order to make arrangements for the payment of dental services.
We collect information from our patients about their health history, their family health history, physical condition, and dental treatments. (Collectively referred to as "Medical Information") Patients' Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.
Patients' Medical Information is disclosed:
If we are ever considering selling all or part of our dental practice qualified potential purchasers may be granted access, as part of the due diligence process, to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all of the information.
Dentists are regulated by the British Columbia Dental Association and College whom may inspect our records and interview our staff as part of the regulatory activities in the public interest.
I consent to the collection, use and disclosure of my personal information as set out above.
Patient Consent Form Covid-19
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