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    Guelph Royal Dental

    18 Douglas St,
    Guelph, ON N1H 2S9
    Phone: (519) 837-1870

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  • Responsible Party Information Insurance Information

    *Please note, patient is responsible with providing us a copy of their insurance card(s).*

  • Primary

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  • Do you or have you ever had an adverse reaction or allergy to:
  • (List any additional meds you take on separate sheet)
  • Consent for Services & Office Agreement

    * I understand that my family’s appointments are valuable, and that 2 Business days must be given if we are unable to attend appointments. A missed standard appointment may incur a fee.

    *I will be required to pay for my family treatment at each visit. For treatment involving laboratory work, I will be required to place a deposit for the estimated lab work required (this is separate from Dental office fees).

    *I understand that outstanding account balances will be passed to a Credit Agency and/or to the Ontario Court System.

    *I understand there are premium times in great demand. If I am not attending these premium appointments and thus preventing other patients from making effective use of these times, I will be required to make use of regular hours for treatment.

    *My dental insurance plan is a contract between myself and the organization providing me with the coverage.

    It is my responsibility to ensure that the treatment I request is covered. However, Guelph Royal Dental Centre will help me to the best of their abilities to ensure accurate and timely completion of my insurance forms. Guelph Royal Dental Centre has NO knowledge of what is covered by my insurance plan. If I have a booklet, Guelph Royal Dental Centre will be able to interpret it for me. Many plans require Pre-Determinations to be forwarded for more extensive treatment. Guelph Royal Dental Centre will complete these for me. To avoid any delays in receiving my payment from my insurance company I must send my claim immediately, if it is not submitted electronically.

    * Guelph Royal Dental Centre also understands that your time is valuable so we are intent on starting your appointment on time. With the possible exception of short notice emergencies (which all of us might get and we would like to be seen as soon as possible) we will not double book appointments.

    * Guelph Royal Dental Centre will always make every attempt to see emergency cases promptly.

    * Guelph Royal Dental Centre will accept Visa, MasterCard, debit, cash or cheque.

    * Guelph Royal Dental Centre will propose my dental treatment with my long-term dental health in mind, and will do their best to give an accurate estimate.

    Consent for Collection, Use and Disclosure of Personal Information

    * I agree that Guelph Royal Dental Centre has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. I can request to see a copy of the consent form and agree the personal information may be collected, used and disclosed as set out in the Privacy Policy of the Office which is in accordance with the Personal Health Information Protection Act, 2004.

About Guelph Royal Dental

At Guelph Royal Dental Centre, we are committed to providing comprehensive dental care for the entire family. We offer a wide range of services, including periodontal surgeries and treatment, as well as dental implants. Offering most procedures in house means patients can receive treatment as promptly as possible.

Guelph Dentist Office

Guelph Royal Dental
18 Douglas St,
Guelph, ON N1H 2S9
(519) 837-1870
[email protected]

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