Welcome to Toothcrew family Dental Please kindly complete our Confidential New Patient Information.

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, home & work telephone numbers, and email addresses. Contact information is collected and used for the following purposes:

• To open & update patient files.


• To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts.


• To process claims for payment or reimbursement from third‐party health benefit providers and insurance companies.


• To send patients informational material about our dental practice.


• 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 for diagnosing dental conditions and providing dental treatment.


Patients’ Medical 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 patients’ behalf.


• To other dentists and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining the second opinion.


• To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment.


• To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion.
  
• To other health care professionals such as physicians if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment.


• 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 personal information.


• Dentists are regulated by the Alberta Dental Association and College which may inspect or records and interview our staff as part of its regulatory activities in the public interest.

Toothcrew Family Dental is hereby authorized to maintain the “Patient(s)” financial information in its records in order to make arrangements for payment of dental services from the Patient’s benefits provider(s). Toothcrew Family Dental accepts the assignment (direct billing) of dental benefits for the Patient’s convenience. If you request direct billing to your dental plan, a valid credit card is required to be left on file. This card will also be charged for any unforeseen balance not collected at the time of the visit and not paid by your dental benefits plan. Toothcrew Family Dental agrees not to disclose credit card information to third parties or to use credit card information unless authorized by the Patient to do so. The patient hereby agrees that amounts owing after payment of insurance benefits will be charged to the Patient’s credit card unless alternative arrangements are made and agreed to by both Parties.

With regard to dental health benefit plans, it should be realized that the plan is between the benefits company and the employee (i.e. patient) and as such the details of coverage are unknown to Toothcrew Family Dental. Toothcrew Family Dental will attempt to estimate the cost of the proposed treatment as accurately as possible. However, in the event of a discrepancy between the estimated cost and the actual cost of the treatment, the difference will be the responsibility of the account holder.

CANCELLATION POLICY

If it becomes necessary to cancel an appointment, I understand that 48 hours notice is required for cancellation of that appointment. There will be a $75 per hour fee for missed or no-show appointments which will immediately be charged to my credit card on file without further notice.