Insurance Information and Agreement - 7Dental

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The safety of our patients is our top priority – please read this important message regarding our new procedures.

COVID Treatment Consent Form

Appointment Request

Request Appointment

Location Information
Please choose the Location(s) you wish to attend:*
- Central Park
- Blossom Park
- Findlay Creek
- Tenth Line
- Trim Social
- Knata South
- Any Location
Patient information
Your Name:*
First Last
Date of birth:*
YYYY dash MM dash DD
Sex:*
Your Email:*
Phone*
Is this a mobile number ?*
- Yes
- No
Are you already a patient of 7Dental?*
- Yes
- No
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Current 7Dental Location:*
What type of appointment would you like?
- Complete Oral Exam
- Dental Cleaning & Checkup
- Denture Consult
- Ortho Consultation
- Invisalign™ Free Smile Assessment
- Other
type of appointment would you like:
How did you hear about us?

Appointment Request

Request Appointment

Location Information
Please choose the Location(s) you wish to attend:*
- Central Park
- Blossom Park
- Findlay Creek
- Tenth Line
- Trim Social
- Knata South
- Any Location
Patient information
Your Name:*
First Last
Date of birth:*
YYYY dash MM dash DD
Sex:*
Your Email:*
Phone*
Is this a mobile number ?*
- Yes
- No
Are you already a patient of 7Dental?*
- Yes
- No
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Current 7Dental Location:*
What type of appointment would you like?
- Complete Oral Exam
- Dental Cleaning & Checkup
- Denture Consult
- Ortho Consultation
- Invisalign™ Free Smile Assessment
- Other
type of appointment would you like:
How did you hear about us?

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LOCATIONS
SERVICES
INVISALIGN
SPECIALTIES
PATIENTS
FORMS

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ABOUT
LOCATIONS
SERVICES
INVISALIGN
SPECIALTIES
PATIENTS
FORMS

Appointment Request

Request Appointment

Location Information
Please choose the Location(s) you wish to attend:*
- Central Park
- Blossom Park
- Findlay Creek
- Tenth Line
- Trim Social
- Kanata South
- Any Location
Patient information
Your Name:*
First Last
Date of birth:*
YYYY dash MM dash DD
Sex:*
Your Email:*
Phone*
Is this a mobile number ?*
- Yes
- No
Are you already a patient of 7Dental?*
- Yes
- No
Address
Street Address Address Line 2 City Province Postal Code
Current 7Dental Location:*
What type of appointment would you like?
- Complete Oral Exam
- Dental Cleaning & Checkup
- Denture Consult
- Ortho Consultation
- Invisalign™ Free Smile Assessment
- Other
type of appointment would you like:
How did you hear about us?
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Dental Emergency

ABOUT
LOCATIONS
SERVICES
INVISALIGN
SPECIALTIES
PATIENTS
FORMS

Hidden
Date
YYYY dash MM dash DD
Insurance Information
Insurance Policy Holder:*
First Last
Policy Holder Date Of Birth:*
YYYY dash MM dash DD
Insurance Company:*
Insurance Company Name:*
Insurance Company Phone # :*
Certificate # :*
Group # :*

List of others insured under this policy:

First Name	Last Name	Date Of Birth	Relationship to Policy Holder

Direct Billing to Insurance Agreement
The clinic will accept to receive payments directly from my insurance company with the following provisions:
- I, the account holder will be responsible to pay any amount not covered by the insurance company at the time the services are provided to anyone covered under this policy.
- If my insurance company fails to settle any submitted claim within 20 days from the date of claim submission, I will be responsible to pay the full amount and have my insurance reimburse me instead. Any unpaid balance over 30 days from the day of treatment will be subject to interest accumulation of two (2%) percent per month.
Policy Agreement*
- I have read, understood and agreed to the above conditions.
Account Holder:*
First Last
Mobile Phone # :
Other Phone # :
_________________________________
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Dental emergency? Call us!

613-7DENTAL ( 733-6825 )

Appointment Request

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+1-613-733-6825
admin@dentalsupport.ca

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