JM Dental New Patient Form
PERSONAL DETAILS
Your personal details. Please review them and make any necessary adjustments.
DENTAL INFORMATION
In the following sections, please select whichever applies. Your answers are for our records only and will be kept confidential in accordance with applicable laws. Please note that during you initial visit you may be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.
MEDICAL INFORMATION
Dental professionals primarily treat the area in and around your mouth, but since your mouth is part of your body, any medication you are taking and your health History have a important relationship with your Dental Treatment. Please answer the following question.
Please go over the following section and indicate which of the following you have or have had. If you need to add any further information, please ente
CHILDREN ONLY
INSURANCE INFORMATION
Your coverage details. Please review them and make any necessary adjustments.
Primary Insurance
Secondary Insurance
Cancellation Policy

We require a minimum of 24 hours’ notice to change and/or cancel appointments. If you fail to cancel your appointment or do not show for your appointment, we do reserve the right to charge you a fee of $100 for the time we have lost.

We will make every effort to accommodate your change or cancellation with the proper 24 hours’ notice provided. 

Thank you for your cooperation!

How Our Office Collects, Uses and Discloses Patients’ Personal Health Information
This office will collect, use and disclose personal health information about you for the following purposes:
• to deliver safe and efficient patient care
• to identify and to ensure continuous high quality service
• to assess your health needs
• to provide health care
• to advise you of treatment options
• to enable us to contact you
• to establish and maintain communication with you
• to offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care generally
• to communicate with other treating health care providers, including specialists and general dentists who are the referring dentists and/or peripheral dentists
• to allow us to maintain communication and contact with you to distribute health care information and to book and confirm appointments
• to allow us to efficiently follow-up for treatment, care and billing
• for teaching and demonstrating purposes on an anonymous basis
• to complete and submit dental claims for third party adjudication and payment
• to comply with legal and regulatory requirements, including the delivery of patients’ charts and records to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the Regulated Health Professions Act
• to comply with agreements/undertakings entered into voluntarily by the member with the Royal College of Dental Surgeons of Ontario, including the delivery and/or review of patients’ charts and records to the College in a timely fashion for regulatory and monitoring purposes
• to permit potential purchasers, practice brokers or advisors to evaluate the dental practice
• to allow potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale
• to deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability and quantify damages, if any
• to prepare materials for the Health Professions Appeal and Review Board (HPARB)
• to invoice for goods and services
• to process credit card payments
• to collect unpaid accounts
• to assist this office to comply with all regulatory requirements
• to comply generally with the law
By signing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal health information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal health information, we will seek your approval in advance.
Your personal health information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA.
You may withdraw your consent for use or disclosure of your personal health information at any time.
I have reviewed the above information that explains how your office will use my personal health information, and the steps your office is taking to protect my information.
JM Dental Financial Policy
JM Dental’s Financial Commitment to our patients

We will bill your insurance directly.

We will aim to get your insurance coverage details when your policy permits, to help you understand your coverage. Furthermore we will also coordinate your benefits if you have dual insurance. 

When financial circumstances are challenging, JM Dental offers no interest financial payment plans to cover your needed dental treatment(s).  


Patient Financial Responsibilities

You will provide a credit card on file when we are unable to confirm your insurance breakdown. 

*We will only charge your credit card once you have agreed to proceed with the treatment. Any insurance payment received in excess to the charged credit card amount will be reimbursed.

When your insurance provider does not provide us with a verbal insurance breakdown of your insurance policy, you are required to provide your documentation of your dental coverage. 

When booking an appointment with our in office Dental Specialist(s), you are required to make a $300 non-refundable deposit towards your treatment.

Depending on your insurance policy there may be a copayment that is required by your insurance provider.

What are co-payments?


Co-payment—also called co-insurance—is the portion of the bill that is your own responsibility. It's the most common way for dental plans to limit their costs, thereby providing various plans with an assortment of benefits and price points for the purchaser to choose.

Patient Signature
Thank You