Medical form

Medical form 

In order to facilitate your appointment with Mon Destiste Lasalle, we encourage you to complete the medical questionnaire below. All the shared information will allow us to create the best conditions for your dental treatment. All information provided will remain strictly confidential and will only be used for your treatment.

 

Do you or have you ever suffered from :

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Calculation for human identification:25+5 =

Policy of the clinic

  • Method of payment we accept at our clinic is cash, Debit/Interact, Credit Cards (Visa and MasterCard), Dentoplan
  • Treatment must be paid in full on the day of appointment.
  • Insurance case: Your insurance company may respond immediately, in such a case you pay the balance. If your insurance responds that the demand has been accepted but will be treated later (or they cannot receive the response electronically), the patient must then pay the total of the treatment immediately. A reimbursement check will be issued to you if your insurance sends the check to our clinic.
  • he patient is responsible for knowing the details of their dental insurance coverage. For example: treatments covered, maximum annual coverage, franchise and frequence of dental cleanings. In the case that a dental treatment is not covered by the patient’s insurance, Mon Dentiste is not to be held responsible. The patient must then pay the total amount of the dental treatment. 
  • We wish to inform you that we do everything we can to provide a thorough and accurate dental examination. However, changes may be made to your treatment plan. If these changes occur, we will notify you prior to any treatment.
  • If a patient arrives late, another appointment will have to be scheduled.

  • If a patient misses many appointments without notice, their file will be closed.

  • Cancellations of appointments must be made at least 48 hours in advance or a fee of $45 will be charged to the patient’s file.
  • We do not tolerate disrespect towards any of our employees. In the event that a situation would occur, we reserve the right to close your patient file at our clinic.

 

I accept the above mention conditions:

                                                                                                                       

7199 Boulevard Newman,
Lasalle, H8N 2K3

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