ROYCREST DENTAL CENTRE

Forms

FirstName:

LastName:

Date Of Birth:

Gender:
M: F: 

Reference By:

Address:

City/Town

Province:

Postal Code:

Phone:

Secondary Phone:

Employer:

Occupation:

EMERGENCY/MEDICAL INFORMATION

Form of ID:[Driver's License, Passport, Birth Certificate etc.]

Number:

Expiration Date:

Emergency Contact:

Phone:

Relation:

Physician

Phone

Medical Specialty

Phone

Area Specialty:

FINANCIAL INFORMATION/PERSON RESPONSIBLE ACCOUNT

Complete the following if information is different from above.

FirstName:

LastName:

Date Of Birth:

Gender:
M: F: 

Reference By:

Address:

City/Town

Province:

Postal Code:

PRIMARY INSURANCE

Subscriber Firstname

Subscriber Lastname

Date of Birth:

Insurance Company

Employer/Policy Holder

Policy Number:

Certificate/ID:

Div:

SECONDARY INSURANCE

Subscriber Firstname

Subscriber Lastname

Date of Birth:

Insurance Company

Employer/Policy Holder

Policy Number:

Certificate/ID:

Div:

OFFICE POLICY

I understand that when appointments are scheduled, staff and facilities are reserved for me, and that at least two (2) business day notice is required for any changes to my appointment, or a fee may be applied to my account. I agree to pay for services at each visit as they are performed unless other prior arrangements have been made.
Please indicate one of the following with a check mark:



Please note that valid identifications are required for all cheque payment and there is a minimum $50 service charge for any returned payment items, e.g., cheques.

CONSENT

I certify that I have provided accurate and complete personal information and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding any medical and dental history. I authorize ROYCREST DENTAL Centre, the registered business name of Dr. Saramma Thomas and the staff to perform diagnostic procedures and treatment that may be necessary for proper dental care. I consent to my physician or specialist being contacted, if necessary, for information that may be required for my dental care. I consent to the performing of dental procedures which have been discussed with me and agreed to be necessary or advisable.

I understand the fees are in accordance with the current Ontario Dental Association suggested fee guide, and I assume all responsibilities for any fees associated with the dental services provided by Dr. Saramma Thomas and staff. I authorize my insurance claims to be submitted electronically where applicable, and understand the full payment is required at the time of services, unless prior arrangements have been approved.

I authorize release to my dental benefits plan administrator and the Canadian Dental Association, information contained in claims submitted electronically. I also authorize the communication of information related to coverage of services described in my claim form to Dr. Saramma Thomas

Guardian:

Dr. Saramma Thomas

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