PATIENT INFORMATION

    Patient Name

    Date of Birth

    Address

    City

    Province

    Postal Code

    Home Phone #

    Cell #

    Email

    Work #

    Occupation/Employer

    Referred By

    FINANCIAL POLICY

    The following is a statement of our financial policy.

    • Payment is due at the time service is provided. Our office accepts Cash, Debit, Master Card, Visa and Personal Cheques.

    • As a courtesy to our patients we will accept payment directly from your insurance company.

    • Please understand that we provide estimates to you, however it is not a guarantee
      that your plan will pay exactly as estimated. Your insurance plan and benefit coverage ultimately determines the amount paid.

    • All charges you incur are your responsibility regardless of your insurance coverage.
      We must emphasize that as your dental provider, our relationship is with you, our patient, not your insurance plan.

    • We ask that our patients be aware of their own insurance policy benefits including the financial and frequency limitations.

    • We ask that you notify us of any changes to your policy prior to dental appointments.

    Primary Dental Plan

    Name Of Insured

    DOB

    Ins Company

    Group #

    ID #

    Employer

    Secondary Dental Plan

    Name Of Insured

    DOB

    Ins Company

    Group #

    ID #

    Employer


    I, , authorize the release of the information contained in claims submitted to my insurance company plan administrator. I also authorize the release of information pertaining to my dental coverage and benefits to Dr. Tyler Crowe Inc. This authorization will apply to any insurance coverage in effect at any time and will remain in effect until the undersigned revokes the same.

    PATIENT CONSENT


    I, the undersigned, hereby authorize the doctor to take x-rays, study models, photographs or any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of my dental needs. I authorize the doctor to perform any and all forms of treatment, medication and therapy, that may be indicated and consent to the use of local anesthetic agents. However, I reserve the right to refuse one or any of the above recommended forms of treatment.


    I understand the above statements regarding payment of fees and accept the responsibility for payment for dental services provide for myself or my dependents, due and payable when services are rendered unless other financial arrangements have been made.



    Appointment Policy: A notice of 2 business days must be given for the cancellation or rescheduling of all appointments to avoid short notice cancellation or missed appointment fees.

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