New Patient Form

New Patient Registration

 

  • DENTAL INSURANCE

  • DENTAL HISTORY

  • MEDICAL HISTORY

  • FOR WOMEN

  • TWO PAYMENT OPTIONS ARE AVAILABLE - PLEASE CHOOSE ONE ONLY

    Please provide your credit card details and drivers licence No. to reception at your first appointment.
    All accounts are paid at the time of Service. The cheque is mailed by your insurance, made payable to the subscriber and you may receive it in as little as 3 days.
    In order for Quarry Park Dental to accept payment from your insurance, our office requires the following: 1. Any portion not covered by insurance must be paid at time of service 2. Valid Alberta Drivers Licence 3. All accounts to be cleared within 45 days from treatment date otherwise a 15% interest charge will occur 4. Quarry Park Dental will be asking for a credit card to remain on file if we are accepting the assignment
  • POLICIES

    Please initial by each box to indicate you have read these policies
  • This field is for validation purposes and should be left unchanged.