Patient Information Form

Please take a moment to enter or update your information to help us ensure the quality of your care is excellent.

Whom may we thank for referring you to East Chestermere Dental?
If applicable

Women Only:

Insurance

East Chestermere Dental depends on reimbursement from patients and/or their benefits for costs incurred in their care. Our office can file dental claims on your behalf, but are not a party to any insurance programs or contracts. Your dental benefits are a contract between yourself, your employer and your insurance provider. Per the Privacy Act, your plan details will not be released to us, as it is confidential medical information.

For dental services that I have consented to, I will assume responsibility for associated fees. I understand that financial responsibility on the part of each patient must be determined before treatment. An interest charge of 18% per annum will be charged on balances exceeding 90 days, unless previous written agreements are satisfied. I assume responsibility for all costs, should I have any delinquent balances forwarded to a third party collections agent.
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