Office Policy Form

WELCOME TO SANDHURST FAMILY DENTAL CLINIC

We would like to thank you for choosing our office for your dental needs. It is our optimal goal to provide you and your family with the highest quality of dental care, while maintaining a friendly and relaxing environment. You will be pleased to know that our office is equipped with digital x-rays which deliver 80% less radiation. We have invested in state of the art sterilization equipment to keep you and your family safe. We use the most up to date methods of sanitation and our equipment is checked daily to ensure it is sterilizing properly.

There are many times when our patients require urgent or emergency treatment and therefore require an appointment as soon as possible. When patients give the clinic advance notice of their need to cancel a scheduled appointment, this time can in turn, be allocated to those patients in need of urgent treatment. In this way the clinic can best serve the needs of ALL patients.

Bearing this in mind, we do request that you give us 48 hours notice, if you need to reschedule or cancel your appointment. A $40 charge is applied for a missed appointment or any short notice cancellation (exceptions will be made for sudden illness or personal tragedy). As a courtesy to you, we provide a week as well as day before reminder call/email. We require that these calls/emails be returned confirming your appointment.

If you have dental insurance coverage, it is your responsibility as the client to know exactly what your dental plan covers. We are sometimes able to assist in getting your coverage details, however not all plans allow us to know the details. Ultimately, you are responsible for understanding your dental plan, including knowing if you are eligible for dental treatment, limitations, total cost reimbursement, and portions payable by you. Our dental fees are based on the current year fee guide, which is set by the Ontario Dental Association.

Our office is equipped with Electronic Submission of dental claims. There are however a limited few dental plans that still do not accept this mode of transmission. Manual claim forms may be necessary and mailed to the insurance company. It is your responsibility as the patient for paying for the treatment.

As long as your insurance allows Assignment of Benefits (allowing the insurance payment to be paid to us), this can be arranged for you. We request that you provide us with your insurance information before your appointment so we can set up direct billing. Any amount not covered by the insurance plan is your responsibility. Accepted forms of payment are Visa, MasterCard, Debit, and Cash.

Our office staff understands the importance of protecting your personal information and we are committed to collecting, using, and disclosing your personal information responsibly. We will only collect, use, and share the information contained in your dental records, including personal information, photos, x-rays, and clinical information, as is reasonably necessary for the following: To communicate with other health care providers, including specialists, general dentists, and doctors as it pertains to your health care or for lawful identification purpose. To obtain information from your dental plan insurance provider on dental coverage and benefits for the purpose of assisting you with estimates, pre-authorizations for treatment, claims, and accepting assignment of payment for claims on your behalf. For the purpose of billing and maintaining contact with our patients.

I have read the above policies of Sandhurst Family Dental Clinic and understand my responsibilities as a patient. I consent to the collection, use, and disclosure of my personal information as set out above and this consent shall continue in effect until the undersigned revokes the same.