Cochrane Dental Child Online Patient Forms

Fill out the Child New Patient forms below and press the submit button after completing each form.
Please fill in each form in its entirety.

Please fill out one form per child. This will help us speed up the initial check-in process.

PLEASE BE SURE TO REQUEST AN APPOINTMENT BEFORE COMPLETING THESE FORMS


Please select the form you wish to complete below.

    Welcome to Cochrane Dental! Please kindly complete your Child's Confidential Patient Information form.

    ABOUT YOUR CHILD

    APPOINTMENT CONFIRMATION PREFERENCE

    MOTHERS INFORMATION

    FATHERS INFORMATION

    LEGAL CUSTODY

    IN THE EVENT OF AN EMERGENCY WHO SHOULD WE CONTACT?

    CHILD'S DENTAL INSURANCE INFORMATION

    Primary Dental Insurance Information
    Coverage

    How many units of scaling are covered? How often does your plan cover dental examinations?


    Secondary Dental Insurance Information
    Coverage

    How many units of scaling are covered? How often does your plan cover dental examinations?

    WHO WILL BE RESPONSIBLE FOR THIS ACCOUNT?

    If another person responsible please complete the following:

    Who is responsible for making appointments?

      CHILD MEDICAL & DENTAL HISTORY



      Has your Child had, or do they have any of the following diseases or medical problems? Please check the appropriate response.


      I understand that the information that I have given is correct to the best of my knowledge, that it will ne held strictest confidence and it is my responsibility to inform this office of any changes in my child's medical status. I also authorize the dental staff to perform the necessary dental services my child may need.

        Personal Information Consent Form

        We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted or required by law.

        We collect information from our patients such as names, home addresses, home & work telephone numbers, and email addresses. Contact information is collected and used for the following purposes:

        • To open & update patient files.
        • To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts.
        • To process claims for payment or reimbursement from third‐party health benefit providers and insurance companies.
        • To send reminders to patients concerning the need for further dental examinations or treatment.
        • To send patients informational material about our dental practice.

        Contact Information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf.

        Financial information may be collected in order to make arrangements for the payment of dental services.

        We collect information from our patients about their health history, their family health history, physical condition, and dental treatments. (Collectively referred to as “Medical Information”) Patients’ Medical Information is collected and used for the purpose for diagnosing dental conditions and providing dental treatment.

        Patients’ Medical Information is disclosed:

        • To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patients’ behalf.
        • To other dentists and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining the second opinion.
        • To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment.
        • To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion.
        • To other health care professionals such as physicians if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment.

        If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.

        Dentists are regulated by the Alberta Dental Association and College which may inspect or records and interview our staff as part of its regulatory activities in the public interest.

        I Consent to the collection, use and disclosure of my personal information as set out above

          OFFICE POLICIES

          Cochrane Dental Centre is hereby authorized to maintain the “Patient(s)” financial information in its records in order to make arrangements for payment of dental services from the Patient’s benefits provider(s). Cochrane Dental accepts assignment of dental benefits for the Patient’s convenience. Cochrane Dental requires that the Patient provide valid and current credit card information to be maintained on the Patient’s file. Cochrane Dental agrees not to disclose credit card information to third parties or to use credit card information unless authorized by the Patient to do so. The patient hereby agrees that amounts owing after payment of insurance benefits will be charged to the Patient’s credit card unless alternate arrangements are made and agreed to by both Parties.

          With regard to dental health benefit plans, it should be realized that the plan is between the benefits company and the employee (i.e. patient) and as such the details of coverage are unknown to Cochrane Dental. Cochrane Dental will attempt to estimate the cost of the proposed treatment as accurately as possible. However, in the event of a discrepancy between the estimated cost and the actual cost of the treatment, the difference will be the responsibility of the account holder.

          When an estimate is requested, Cochrane Dental will be as accurate as possible. Unfortunately, dental treatment complications cannot be entirely foreseen and hence differences between estimates and actual costs can arise. Once again, the difference will be the responsibility of the account holder.

          CANCELLATION POLICY

          If it becomes necessary to cancel an appointment, I understand that 48 hours notice is required for cancellation of that appointment. There will be a $60 per hour fee for missed or no-show appointments which will immediately be charged to my credit card without further notice.

          Below are 2 payment options available to you (& your account). You will be asked in-office to choose which option you would like to participate in.

          Option 1

          Payment is due in full on the day the treatment is completed. We accept Cash, Debit, MasterCard, Visa & AMEX. Your payment will be processed and your insurance documents will be generated and submitted to your insurance carrier; whereupon your insurance carrier will reimburse you directly.

          Option 2

          We will direct bill your insurance carrier. If we receive an explanation of benefits from your insurance carrier following your visit, the outstanding balance will be collected before you leave. If you select this Direct Billing option, you will be required to leave a CREDIT CARD on file. If there is a balance on your account following your insurance company paying Cochrane Dental Centre, this balance will be charged to the Credit Card on file and a receipt for payment will be emailed to you. A credit card is not required for any Government Sponsored Insurance plans (ie. Alberta Works).

          Direct Billing is a courtesy we offer to our patients and in order 'Direct Bill' your insurance provider, we require a credit card on file or any outstanding amounts owing after your insurance provider has paid their portion. Outstanding account balances over 60 days will be charged 2% interest monthly. I hereby agree to the Financial Policy of Cochrane Dental Centre as outlined above, and authorize Cochrane Dental Centre to apply any outstanding balance on my account that is not covered by my insurance provider to your credit card on file.



          Thank you in advance from the Team at Cochrane Dental!