At Innovation Drive Dental payment is due when services are rendered. If you have dental insurance we will submit the claim on your behalf and accept reimbursement from your insurance directly according to your policy specifications. Our office policy requires any insurance differences or services not covered to be paid by the patient on the day of the appointment. Our fees are based on the ODA Fee Guide for the current year. We accept Visa, MasterCard, Debit, Cheques and Cash. If you have any questions regarding our fees, please inquire.
Primary dental insurance
Secondary dental insurance
I the undersigned, state that I have completed all information forms accurately, without knowingly omitting information. On the basis of confidentiality, I herby consent to the release and transfer of any patient information and dental records within my file for dental insurance purposes or inter-practitioner communication. I agree that Innovation Drive Dental has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. Please note that personal information used, disclosed, secured or retained by Innovation Drive Dental will be solely for the purposes for which we collected it and in accordance with the National Privacy Principles contained in the Personal Information Protection and Electronic Documents Act.
I agree that the electronic signature above will be an electronic representation of my signature for all purposes, just the same as pen-and-paper signature.
Please check any of the following that may apply to you:
Sensitive teeth (hot/cold/sweets)
Have you ever had complications following medical treatment?
On a scale of 1-10, how important is your dental health?
(1=not important; 10=very important)
I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my
knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my
I understand that I am financially responsible for services rendered to me or to my dependents that are not fully covered by my
insurance (if applicable) and I may be billed for this remaining balance. I agree to pay all uninsured services or insurance
differences at the time services are performed, unless other arrangements are made.
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