New Patients - Viva Dental

Name*
Birth date
DD slash MM slash YYYY
Sex*
- Male
- Female
Marital status*
- Married
- Single
- Other
Address*
Postal code*
Saskatchewan health card number*
Home phone
Work phone
Cell phone
Email address*

Receipts will be emailed
Employer
Position
Dental insurance*
- Yes
- No
Emergency contact*
Phone*
Name of spouse or parent (if under 18)
How did you hear of our office?*

Primary
Insurance company name
Group number
Certificate number
Division number
Name of policy holder
Birth date
DD slash MM slash YYYY
Yearly maximum
Secondary
Insurance company name
Group number
Certificate number
Division number
Name of policy holder
Birth date
DD slash MM slash YYYY
Yearly maximum
Supplementary health benefits
- Yes
- No
First Canadian Health
- Yes
- No
Status number

Patient Consent*
I agree
I hereby consent to allow all necessary dental procedures and services to be performed. This may include x-rays and or dental freezing. I understand there are limitations with certain procedures and in some instances, complications may occur. I certify that I have read and understood the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If I ever have changes in my health I will inform the doctor at my next appointment without fail.
Signature of patient or guardian*
Date*
DD slash MM slash YYYY
With the introduction of the new Health Privacy Act and the diversity of dental benefit packages more dentists are not accepting insurance as payment. We would like to be able to continue to offer our new and existing patients flexibility in paying for dental treatment with the following options.
Payment Options*
- Fee for service:
  
  This option allows you to be in control of your insurance benefits by paying in full at each appointment for treatment and being reimbursed directly by your insurance company. This will enable you to keep personal records of all dental transactions, all insurance reimbursements, track maximum allowable benefits and you will be more aware of what your plan does and does not cover. You will not have to come in to pay outstanding balances, or receive possible refunds. Monies to insurance subscribers are generally received within two weeks when submitted electronically.
- VIP express checkout:
  
  Our VIP Express Checkout Program allows us to continue to offer you the convenience of using your insurance plan as a form of direct payment. Please complete the information below. It will be kept confidential and used only under the agreed terms.
Credit Card Authorization and Consent Form
Agree*
I hereby authorize Viva Dental Studio to charge my credit card for any balance of account after insurance payment.
Type of card*
- Visa
- Mastercard
- American Express
Credit card number ends in (last four digits)*
Expiration date*
Name of cardholder*
Credit card billing address*
Signature of authorized cardholder*
By submitting, I acknowledge the charges and assume full responsibility for said charges and agree to honour and abide by the terms of payment.

SASKATOON DENTIST

Welcoming New Patients

For your first visit to our clinic:

Patient Intake Form

Primary

Secondary

Credit Card Authorization and Consent Form