KUZDENYI DENTISTRY

PATIENT - INFORMATION

Last Name:____________________________   First Name:___________________

Date of Birth:__________________________

Address:______________________________________________________________

Home Phone:________________________ Cell Phone:________________________
 **Please circle the telephone number where we can best reach you or leave a message**
Can we text you or leave a message?   YES     NO 

Email Address:_________________________________________________________

EMERGENCY CONTACT - INFORMATION

Name:____________________________   Phone #: ___________________________

 ASSIGNMENT  AND RELEASE: I authorize release, to my dental benefits plan administrator and the CDA, information in claims submitted electronically. I assign my insurance benefits to be paid directly to Kuzdenyi Dentistry. I understand I am financially responsible for the PORTION NOT COVERED by my benefits at the time of service. I authorize Kuzdenyi Dentistry to release any information required to process my claim to my insurance company. 

 PLEASE NOTE:
The Canadian Dental Care Plan(CDCP) will only pay for dental care services covered within the plan at the established CDCP fees. These fees are lower than the Ontario Dental Association's suggested fee guide. If you are covered under the CDCP you are responsible to pay any additional charges at the time of service.

 MISSED APPOINTMENTS: We require 48 hours notice for appointment cancellations. Missed appointments without notice will incur a fee of $50 - $100.  It is required for this fee to be paid before any further appointments can be booked. 

I have read and agree to the policies of this office.

Name:_______________________________

Signature: _______________________________  Date: _______________