New Patient Form
Fairway Dental Clinic
385 Fairway Road South, Unit #203
Kitchener, Ontario, Canada N2C 2N9
Preferred Gender Pronoun
A pronoun is a word that substitutes for a noun; in this case, a word that substitutes for your name. We want to know what to call you!
*Please note, patient is responsible with providing us a copy of their insurance card(s).*
Medical & Dental Information
Do you or have you ever had an adverse reaction or allergy to:
Have you ever had any of the following? Please check those that apply:
If you had any surgeries please specify the surgery date and information.
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, Fairway Dental Clinic will help me to the best of their abilities to ensure accurate and timely completion of my insurance forms. Fairway Dental Clinic has NO knowledge of what is covered by my insurance plan. If I have a booklet, Fairway Dental Clinic will be able to interpret it for me. Many plans require Pre-Determinations to be forwarded for more extensive treatment. Fairway Dental Clinic 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.
* Fairway Dental Clinic 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.
* Fairway Dental Clinic will always make every attempt to see emergency cases promptly.
* Fairway Dental Clinic will accept Visa, MasterCard, debit, cash or cheque.
* Fairway Dental Clinic 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