All information will be kept strictly confidential. It is used in providing safe and accurate treatment.
Dental Benefits / Insurance
I authorize release to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to North Hill Dental and also the use of my signature on all insurance submissions. I hereby assign my benefits, payable from claims submitted electronically, to North Hill Dental and authorize payment directly to them.
This authorization shall continue in effect until the undersigned revokes the same.
Dental Anxiety / Sedation
Dental History and Oral Hygiene Habits
Medical History and Health Questionnaire
Current Medications (or in the past year)
Do you presently have or have you ever had any of the following? If yes, then check the box.
I certify that I have provided an accurate and complete medical and dental history and have not omitted any information. I have had the opportunity to ask questions and have received answers regarding any concerns. I authorize the North Hill Dental team to perform and provide treatment as required. I also understand that the premises are under CCTV monitoring and I consent to this. I authorize the team to contact my physician regarding any relevant medical conditions.
By submitting this form, you confirm that you have read and understood the Terms and Conditions, Privacy Policy, and Terms of Use of North Hill Dental Center prior to submission, and you agree to them. You can review these documents here:
Terms and Policies.
I consent to the collection, use, and
disclosure of this personal information for myself, or as the guardian of the patient in this form and accept all policies mentioned above.
By submitting this form, I acknowledge that I have read and agree to the Terms and Conditions, Privacy Policy, and Terms of Use of North Hill Dental Center.
