Dental and Medical History Update

It is the practice of our office to see all our patients on an appointment basis. If you are unable to keep your appointment, we request that you notify us at least 2 business days prior to your appointment. Patients who fail to provide us with adequate notification time may be charged a short notice cancellation or missed appointment fee.

We offer a reminder notice two days before your appointment. Please note that this is a courtesy notice. If you do not receive our notice, you are ultimately responsible for missing the appointment that you scheduled.

Our office provides electronic or manual billing to your insurance provider on your behalf. It is your responsibility to provide accurate and up to date insurance information and to notify us of any changes. For direct billing, we require a credit card to be kept on file. This card will be used to cover any patient portions due at the time of service, as well as any remaining unpaid balances after insurance. A receipt will be sent to you via email or mail for each transaction. All payment and personal information will be securely stored in the Moneris Vault and kept strictly confidential in compliance with data privacy regulations.

Due to the privacy act, you are responsible to monitor your plan's coverage and maximums. If your insurance does not cover your treatment, you are responsible to cover the cost at the time each service is rendered unless other arrangements have been made.

All fees charged are those set out by the College of Dental Surgeons of Saskatchewan.

*Please let reception know if your insurance information has changed or if you are now covered by the Canada Dental Care Plan (CDCP)

For direct billing, a credit card is required to be kept on file. If you prefer to pay upfront and submit your claim independently, please inform reception.

Card details are entered directly into Moneris' secure tokenization form below. We never see or store your card number on our website.

If you take multiple medications or you don't remember the names, please let reception know and the dentist can access your prescription records through e-health.

It is the practice of our office to see all our patients on an appointment basis. If you are unable to keep your appointment, we request that you notify us at least 2 business days prior to your appointment. Patients who fail to provide us with adequate notification time may be charged a short notice cancellation or missed appointment fee. If you have any questions or require clarification, please contact our office.

Insurance Balances: I understand that if I have dental insurance, a credit card is required on file. After my insurance provider processes claims, any remaining patient balance will be charged to the card on file. This includes balances not covered by insurance within 60 days of claim submission.

Assignment of Benefits: I may assign insurance benefits to Cumberland Dental only if a valid credit card is on file to cover any remaining balances.

Insurance Reimbursement to Patient: I understand that while most dental insurers pay the dentist directly, some reimburse the patient. In such cases, I am responsible for payment in full at the time of service, and Cumberland Dental will submit a claim on my behalf.

Cancellations and Rescheduling: I agree to provide at least 48 hours' notice for appointment cancellations or rescheduling. I understand that failure to do so may result in a cancellation fee charged to my account.

Future Charges and Receipts: I authorize Cumberland Dental to use the card on file for patient portions due at time of service and any unpaid balance thereafter. A receipt will be provided by email or mail upon each charge.

Ongoing Authorization: I acknowledge that this form serves as continuous authorization for future charges and that no additional verbal, written, or electronic approval will be required for each transaction.

Family Accounts: I understand this agreement applies to all individuals listed under my family account, and the card on file may be used to cover their balances as well.

Confidentiality: All payment and personal information will be securely stored and kept strictly confidential in compliance with data privacy regulations.

I certify that I have read, and I understand the questions above. I acknowledge that my questions, if any, about the inquiries above have been answered to my satisfaction. I will not hold my doctor, affiliated entities, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form. I have read and understood the Cancellation Policy as outlined herein. I agree to the terms described and assume full liability for any fees charged should I fail to abide by these short notice requirements.

I, the undersigned, consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetic as indicated, and will assume responsibility for fees associated with these procedures.