General Consent Form

Clear Dental is committed to providing quality care and taking all possible steps to protect the privacy of our patients and their personal information. All personal information collected will be used in a reasonable and professional manner. This document will summarize the collection, use and disclosure of your personal information. Clear Dental is obligated to disclose any personal information collected when required to by law. Our office ensures that:

• Only information that is absolutely necessary will be collected
• Your information will only be shared with your consent
• Retention and destruction of your personal information is in compliance with the existing legislature and privacy protocols
• The privacy protocols are in compliance with the law

The information collected from our patients (names, home address, work address, telephone numbers, email addresses) referred to as contact information serves the following purpose at Clear Dental:

• To open patient files and keep them current
• To send claims to insurance companies
• To process payments
• To remind patients of future dental exams/treatments/necessary preparations for appointments

This information will be disclosed to third party providers and insurance companies where the patient has designated a claim to be submitted on their behalf.

Financial information including, but not limited to, credit card information could be collected to make payment arrangements for dental services.

Health history, family health history, physical and dental treatments and conditions are collected and used to determine or diagnose dental conditions and provide dental treatment. It is also used to ensure the medical safety of the patient while undergoing treatment.

The disclosure of medical information could happen if:

• Clear Dental is submitting an insurance claim on the patient’s behalf
• The patient consents to getting a second opinion from another dentist or specialist
• The patient consents to being referred to another dentist or specialist
• The patient has been referred to Clear Dental by a physician or non-dental specialist

Dentists are regulated by the Alberta Dental Association and College which regulates the records and interviews staff as part of their office regulatory activities for the benefit of public interest.

Standard headshots, videos, and intra-oral photography/radiography are all used as a part of the Clear Dental routine examination process. These portions of the exam are utilized in the following ways:

• By Clear Dental and any other of the patient’s health care providers for diagnosis
• Patient Education (the visualization of every step of the process, further understanding of what is being treated, and treatment progression)
• Aiding in treatment planning (so dental team members can visualize the patient’s teeth while working on the patient’s case while the patient isn’t in the office)
• To share with other health care professionals or at lectures (with identifying features removed) to scientific, social, or medical audiences for educational purposes

Clear Dental strives to provide our patients with the best-suited personalized dental treatment plan for their individual patient needs. The treatment cost estimates given to you in your treatment plan will be honored for 90 days from the date the treatment plan was presented. Beyond this time period costs are subject to change.

Out of respect for all patients as well as the staff at Clear Dental, if a patient arrives more than 15 minutes late for their appointment, Clear Dental reserves the right to decline service. The appointment may be rescheduled.

At Clear Dental, we strive to give each patient the best service and attention possible and therefore block off the entire time slot allotted for each appointment with the dentist and supporting staff. We ask that our patients show us the same respect. Therefore, all cancellations must be made at least 48 (business) hours prior to your appointment. If there is a cancellation within that 48-hour time period there will be a $100 cancellation fee.

I acknowledge that I am aware of the reasons my information is being taken and understand that refusing to provide any of this information will result in the inability of the dentist to properly administer my oral care.

Clear Dental accepts the following payment methods: Visa, MasterCard, Debit, bank draft, certified cheque, and personal cheque.

Please Note:

• A $100 fee will apply if a personal cheque is returned due to insufficient funds.
• A $100 fee will also apply if a credit card left on file for automatic payment is declined.
• If an account remains unpaid and we do not receive a response within three (3) months of treatment completion, the account may be referred to a collection agency, and a 3% monthly interest charge will accrue on the outstanding balance.

Please make sure to pay your balance in full within the given timeframe to avoid any penalties.

Clear Dental is happy to provide all the necessary documentation for you to submit your dental claims directly to your insurance provider. However, full payment is required at the time of service.

For your convenience, Clear Dental offers direct billing to your insurance provider. We will submit dental claims on your behalf and receive payment directly from your insurer.

Please Note:

• You are responsible for any portion of the treatment not covered by your insurance.
• This includes co-pays, deductibles, and amounts not covered due to unknown or incomplete insurance details
• These balances are due in full on the day of service

Full payment is required on the day of your tooth preparation or impression appointment if:

• A Predetermination of Benefits or Explanation of Benefits has not been received, or
• Your insurance plan does not cover crowns, bridges, or other major prosthetic treatments.

If your insurance only covers part of the treatment, the remaining balance—along with a deposit for lab fees and material fees—will be collected on the day of your tooth preparation or impression appointment. If your insurance confirms full coverage, we’ll still collect the full amount of any lab and material fees on the day of your tooth preparation or impression appointment. The material fee and lab fee that we collected will be refunded to you once we receive the insurance payment in full. However, if you’re unable to continue with your treatment at Clear Dental after we’ve sent your case to a thirdparty dental lab, we’ll gladly refund payments you’ve made toward the treatment you are not able to continue— except for the lab/material fee deposit, which is non-refundable in this case due to the work already started by the lab.

• Clear Dental will submit your dental claim and any required diagnostic information to your insurance provider.
• Once payment is received from the insurance provider, Clear Dental will either:

                     • Collect any remaining balance, or

                     • Refund any credit on your account.

If your insurance provider requests additional information

• It is the patient’s responsibility to inform Clear Dental or provide any correspondence from the insurance provider within 15 days. 
• Failure to do so may result in the patient being responsible for any unpaid balance, including any late fees and interest charges due to delayed payment.

Unpaid Balances

• If an outstanding balance is not paid within three (3) months of the procedure date—and after reasonable efforts have been made to contact the patient—Clear Dental reserves the right to forward the account to a collections agency.
• A 3% monthly interest charge will apply to the unpaid balance.

I understand and consent to all of the above. I also understand that I can revoke my consent at any time, but if I decide to do so it must be in writing and signed by myself (patient or guardian) and presented to the Clear Dental Clinic. I authorize release, to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the dentists at Clear Dental.