For Patients

Patient intake forms:

PERSONAL INFORMATION

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PLEASE READ: All professional services are charged directly to the patient and patients are personally responsible for payment of bills on their accounts when treatment is completed. We will prepare any necessary forms or reports to help you collect your benefits from insurance companies.

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MEDICAL / DENTAL HISTORY

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PLEASE READ: All professional services are charged directly to the patient and patients are personally responsible for payment of bills on their accounts when treatment is completed. We will prepare any necessary forms or reports to help you collect your benefits from insurance companies.

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CONSENT FORM

PERMISSION TO COLLECT, USE AND DISCLOSE PERSONAL INFORMATION

Our office understands the importance of your personal information. We will collect and use your personal information for these appropriate purposes:

  • To diagnose and provide safe and efficient health care
  • To assess your oral health and advise you of your treatment options
  • To communicate with you and your other health care providers
  • For scheduling appointments, billing purposes, including dental insurance forms
  • For teaching and demonstration, on an anonymous basis
  • To comply with the College of Denturists, Provincial and Federal regulations and to generally comply with the law
  • To comply with the audits and evaluations of the dental practice
  • To provide invoices, process credit payments and collect unpaid accounts
  • To permit potential purchases or their agents to evaluate and audit the practice in preparation for a potential sale of the practice

By signing this Consent Form you agree that you have provided your personal information. You consent to the collection, use and disclosure of the information for the appropriate purposes listed above. Your information may be accessed by the College of Denturists or other regulatory authorities acting under statute of a legal issue. We will seek your approval, in advance, if a new purpose should arise for the use and/or disclosure. You may withdraw your consent for the use and disclosure of your personal information at any time. We will explain the process and the ramifications of your decision to do so.

I have reviewed the above information that explains how Apple Denture & Implant Solutions will use my personal information. I understand that Apple Denture & Implant Solutions safeguards my personal information and that I have access to it at any time. I know that Apple Denture & Implant Solutions has a privacy code in place and I can review it at any time.

I agree that Apple Denture & Implant Solutions may collect, use and disclose personal information about:

as set out in the office’s privacy policy.

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To download and print the form, click here

Patient-Intake-Forms.pdf

To book an appointment please fill out the form or click BOOK YOUR APPOINTMENT

You can start smiling again

Apple Dentures