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Country Park Dental
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New Patient Form

You are here: Home1 / New Patient Form
1 Medical History
2 Privacy
3 Insurance
  • Country Park Dental

    101-1450 Block Line Road, Unit #101 Kitchener, ON N2C 0A5

    Patient Information

  • Gender

  • 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!
  • Contact Information

  • Responsible Party Information Insurance Information

    *Please note, patient is responsible with providing us a copy of their insurance card(s).*

  • Primary

  • Drop files here or
    Accepted file types: jpg, png, gif, pdf.
  • Secondary

  • Drop files here or
    Accepted file types: jpg, png, gif, pdf.
  • (List any additional meds you take on separate sheet)
  • None of the above

  • Consent for Services & Office Agreement

    *I understand that my family’s appointments are valuable, and 2 Business days notice must be given if we are unable to attend appointments. A standard appointment time will incur a fee.

    *I will be required to pay for my/my family’s treatment at each visit. For treatment involving laboratory work, I will be required to place a deposit for the estimated lab work required (these are separate from Dental office fees). I understand the cost of any proposed treatment will be honored for a period of 90 days and following the 90 days a new exam and/or radiographs may be required at an additional fee if necessary.

    *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.

    *I consent to receiving reminder emails / text messages including marketing or promotional content through smile reminder as well as phone calls & voicemails stating my appointment times or changes necessary.

    *My dental insurance plan is a contract between myself and the organization providing me with the coverage (your insurance company). It is my responsibility to ensure that the treatment I request is covered. However, Country Park Dental will help me to the best of their abilities to ensure accurate and timely completion of my insurance forms. Country Park Dental has NO knowledge of what is covered by my insurance plan. To avoid any delays in receiving my payment from my insurance company I must send my claim immediately, if it is not submitted electronically.

    *Country Park Dental also understands your time is valuable 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).

    *Country Park Dental reserves the right to cancel an appointment, if they are unable to contact the patient & confirm the appointment.

    *Country Park Dental will accept Visa, MasterCard, debit or cash.

    *Country Park Dental will propose my dental treatment with my long-term dental health in mind, and will do their best to give an accurate estimate.

    I have read the above conditions of treatment and payment and agree to their content.
  • Country Park Dental

    101-1450 Block Line Road, Unit #101 Kitchener, ON N2c 0A5

    HOW OUR OFFICE COLLECTS, USES AND DISCLOSES PATIENT’S PERSONAL INFORMATION

    Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined below how our office is using and disclosing your information. This office will collect, use and disclose information about you for the following purposes:
    • To deliver safe and efficient patient care
    • To identify and to ensure continuous high quality service
    • To assess your health needs and advise you of treatment options
    • To enable us to contact you, establish and maintain communication with you
    • To offer and provide treatment, care and services in relationship to oral maxillofacial complex and dental care in general
    • To communicate with other treating health care providers, including specialists and general dentists who are the referring dentists an/or peripheral dentists
    • To allow us to maintain communication and contact with you to distribute health-care information, and to book and confirm appointments
    • To allow us to efficiently follow-up for treatment, care and billing.
    • To complete and submit dental claims for third party adjudication and payment
    • To comply with legal and regulatory requirements, including the delivery of patients’ charts and records in the Royal College for Dental Surgeons of Ontario in a timely fashion, when required according to the provisions of the Regulated Health Professions Act
    • To comply with agreements/undertakings entered into voluntarily by the member with the Royal College of Dental Surgeons in a timely fashion for regulatory and monitoring purposes.
    • To permit potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale
    • To deliver charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability and damages, if any
    • To prepare material for the Health Professions Appeal and Review Board (HPARB)
    • To invoice for goods and services and process credit card payments
    • To collect unpaid accounts
    • To assist that this office comply with all regulatory requirements
    • To comply generally with the law
    By signing the consent of this patient consent form, you have agreed that you have given your informed consent to the collection, use and /or disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and /or disclosure of your personal information, we will seek your approval in advance. Our office has a Privacy Code and you can ask to see it anytime. After reviewing the above information, I agree that, Dr. Sorin Mitrana’s Dental Office, can collect, use and disclose personal information about myself, and my family, as set out in the information about office’s privacy policies.
  • COUNTRY PARK DENTAL

    1450 Block Line Road, Unit #101 Kitchener, ON N2C 0A5

    PATIENT IS RESPONSIBLE FOR OWN DENTAL INSURANCE

    To Our Patients Who Have Dental Insurance,

    We are very pleased that you have selected us to perform your dental treatment. It is our wish that your dental health is the very best, that it can be. With the assistance that your insurance company provides, good dental health is a simple matter.

    Your insurance coverage is an arrangement between your insurance company and your place of employment. There are many different policies and forms of coverage, for example, some plans cover as little as 20% of dental treatment costs, while others cover as much as 100%. Please be aware that your coverage may not be based on the current dental fee guide. The amount of coverage that has been arranged does not involve the dentist. Our staff would be happy to complete your insurance forms and mail them to your insurance company. Your insurance company will in turn send the funds directly to this office. The unpaid portion that your dental plan does not cover, is your responsibility.
    • The out of pocket portion must be paid at each appointment
    • You are responsible for any treatment no longer covered by your dental plan.
    *If you do OR do not have dental insurance, please sign below acknowledging you are responsible for 100% of the payment.*

    Please feel free to ask if you have any questions.

    Patient’s Acknowledgment:

    I have read and understand the above, and agree to assume full liability for fees not covered by my insurance plan.

Contact Us

1450 Block Line Road
Unit 101, Kitchener
Ontario, N2C 0A5

Phone: (519) 569-8881
Fax: (519) 569-8882
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Business Hours

Monday 8:00 AM – 7:00 PM
Tuesday 8:00 AM – 7:00 PM
Wednesday 8:00 AM – 4:00 PM
Thursday 8:00 AM – 7:00 PM
Friday 9:00 AM – 2:00 PM

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