Thank you for considering us for you and your family’s Health and Wellness needs! We look forward to the privilege of being your family’s care provider. Our Dental team strives to provide optimum health and wellness services in our state-of-the-art facility by offering our valued clients professional, safe, and compassionate care. We achieve this through a highly skilled and friendly team of professional health service providers.
We look forward to the privilege of being you and your family’s dental and wellness provider. Our facility is dedicated to quality care and is pleased to reserve time exclusively for each patient. If you are a new client, please download and complete the documents below to help facilitate your intake. Should you have any questions, please contact us at (403) 235-6208. Our friendly administration team will be glad to assist you.
It is important to us that your experience with Lifepath is comfortable and welcoming each time. From the moment you walk into our office and are greeted by our Team, we want you to feel as if you are part of our extended family.
Your wellness provider and their team will take all the time necessary to discuss your specific health levels, needs, and goals.
Our facility is dedicated to quality care and is pleased to reserve time exclusively for each patient. We strive to keep your visit as efficient as possible, ensuring that it starts on time and ends on time. We follow up every visit so that you can provide us with your feedback on how we can further improve on meeting the needs of ALL our patients.
Our goal is to keep you aware of and utilize the latest trends in health and wellness. To accomplish this, we keep in touch with our clients via whatever technology they are most comfortable with. Whether that is by email, text message or even a simple phone call, we will make sure that it fits with your schedule to help you attain your wellness and health goals.
First Name
Last Name
A.H.C. #
Date of Birth
Age
Gender MaleFemale
Home Address
City
Postal Code
Home Phone
Work Phone
Cell Phone
Best Phone number to confirm appointments * Home PhoneWork PhoneCell Phone
Email
Employer
Occupation
Emergency Contact Name
Emergency Contact Relation
Emergency Cell Phone
Whom may we thank for your referral? No ReferralGoogleSocial MediaThe AnchorStrathmore StandardWalk by/Live In AreaPhone Book/Yellow PagesFriend/Co-workerFamily member
If a friend/co-worker referred you, who
If a family member referred you, who
Please check all that apply to you: Aids or HIVAlcohol or drug abuseAnemiaArthritisArtificial valves / joints / pinsAsthmaBlood Disorders / Excessive BleedingHigh Blood Pressure Cancer/ChemoCongestiveHeart FailureDiabetesDizziness / FaintingExcessive BleedingGlaucomaGrowths or TumorsHay FeverHead InjuriesHeart DiseaseHeart MurmerHepatitisSTD / Venereal DiseaseJaundiceKidney DiseaseLiver DiseaseLow Blood PressurePacemakerMental or Nervous DisordersTuberculosisRadiation TreatmentRespiratory ProblemsRheumatic FeverSinus ProblemsSmokerUlcersStomach ProblemsStrokeTMJ ProblemsEpilepsyOther
If yes to Asthma, Do you use an inhaler? YesNo
If yes to Diabetes, Do you use insulin? YesNo
If yes to Hepatitis, what type?
If yes to stroke, when?
If other, please explain
IMPORTANT: Do you require PREMEDICATION (ANTIBIOTIC COVERAGE) for dental treatment? (i.e.: Heart valve problems, heart disorders, artificial hip, etc…) YesNo
Do you have ALLERGIES to? AspirinCodeineErytyhromycinLatexLocal Anesthetic (Freezing)PenicillinSulphaOther
If other for allergies, please list
Have you ever had a reaction to any drug or medication? YesNo
If yes to reaction, please explain
Have you been under the care of a physician recently? YesNo
If yes for under the care of a physician recently, please explain
Have you been admitted to a hospital in the last 2 years? YesNo
If you have been admitted to a hospital in the last 2 years, please explain
List all medications, pills, vitamins or herbs you are presently taking
Previous Dental Office & Dentist’s Name
Last visit
What was done?
Reason for this visit?
Are you currently in any discomfort or pain with your teeth or gums? YesNo
If yes to discomfort or pain, please explain
How would you describe the current condition of your oral health? PoorFairExcellent
Are you nervous or anxious during dental treatment? YesNo
Have you ever fainted or had complications following dental treatment? YesNo
Have you ever had an injury, surgery or x-ray therapy to the face or jaw? YesNo
Are you happy with your smile? YesNo
Do your gums ever bleed? YesNo
Would you like to have whiter teeth? YesNo
Do you clench or grind your teeth? YesNo
Are you unhappy with any silver or discolored fillings? YesNo
Would you like to have straighter teeth? YesNo
Do you have pain in your jaw? YesNo
Thank you for allowing us the privilege of being your Dental Health provider. Our practice is dedicated to quality care and is pleased to reserve time exclusively for each patient.
We respect our patients' time and make every effort to remain on schedule. Despite careful scheduling, dental emergencies can cause delays. If your appointment time is affected due to an unforeseen emergency, we will try our best to notify you in advance. We know that your time, like our Doctor’s, is valuable and we will make every effort to see you on time and will ensure you are given the same time and attention for your dental health.
Because we reserve time exclusively for you, we ask that you make every effort to keep your reserved appointment time. If you find that you cannot keep your scheduled visit,we require a minimum of 2 business day’s notification. Advance notice allows our office to see other patients who may have been waiting to see us for needed treatment. We thank you in advance for your consideration.A charge of $75.00 may apply to your account if sufficient notice is not provided; this charge is at the discretion of your Doctor.
(IMPORTANT: Please read and initial if you request direct billing to your Insurance, if you wish to pay in full for your dental treatment and be reimbursed by your dental plan, please omit this portion.)
Many of our patients have dental insurance. While your dental insurance policy is an agreement between you and your insurance company, we will be happy to assist you in preparing and sending in the necessary forms. Please remember that no insurance company attempts to cover all dental costs. We cannot render dental treatment on the assumption that our charges will be paid in full by an Insurance Company. Full payment to our office remains your responsibility, regardless of how much your insurance does or does not pay. (Please see the attached information on dental insurance for more information.)
I am aware that Lifepath Dental direct bills my Insurance Company as a courtesy to me and that in doing so, the dental office accepts no responsibility for any uncovered amounts, amounts over benefit maximums, limitations or plan restrictions, etc. I understand that the dental office collects my dental coverage information as a guideline ONLY to assist me in maximizing my benefits this does not hold them responsible for my dental account. Lifepath Wellness advises that I make myself very aware of my dental plan, knowing my coverage and that I ask my dental team about any and all procedures I am authorizing.
Please email/bring in a dental plan breakdown (available online through your insurance provider) to chestermere@lifepathwellness.com. Lifepath Wellness advises me to contact my plan administrator or Insurance Company for questions regarding eligible procedures and authorization of treatment. And to make myself aware of all costs involved with my dental care. Lifepath advises me to keep track of my yearly maximums, limitations, appointment dates, and accumulated amounts used on my dental benefit plan.
initial *
Payment is due at the time of service. I am aware that if the dental office does not receive confirmation from my Insurance for their exact payment—Lifepath Dental will estimate my portion only at the time of visit. Any unforeseen balances will then be informed to me by statement. I agree to pay all of these uncovered portions within 10 days from the date of statement or interest charges of 6% per month may be applied to my account. I agree to pay these interest charges if applied to my overdue account.
I also understand that any uncovered procedures that may have been done at another Dental office are my responsibility. IMPORTANT: Please be advised that complete oral examinations (new patient exams) & x-rays will be denied by your insurance if you have had this procedure at another dental office within the time limitations on your specific plan. You are responsible for this procedure in our office should this not be an eligible benefit with your coverage.
I am aware that NSF fees (returned cheques) are $50 for every returned personal cheque.
To the best of my knowledge, all of the preceding answers and information provided are true, complete, and accurate. I grant permission to you and your assignees to telephone me to discuss matters related to this form. I understand that this information is held in the strictest confidence and it is my responsibility to inform the office of any changes to my medical status. I authorize the dental office to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
I, the undersigned, clearly understand all policies of Lifepath Wellness Centre. I understand and agree to pay all fees associated with my dental treatment. With or without Dental coverage, I agree to make myself aware of those fees prior to any dental treatment I authorize to be done.
Date
Printed Name
Signature:
We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances in this form, we also collect, use and disclose personal information when permitted or required by law.
We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers, and e-mail addresses. (Collectively referred to as “Contact Information”.) Contact information is collected and used for the following purposes:
To open and update patient files
To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts
To process claims for payment or reimbursement from third-party health benefit providers and insurance companies
To send reminders to patients concerning the need for further dental examination or treatment
To send patients informational material about our dental materials
To follow up with treatment and/or customer services
Contact information is disclosed to third-party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf.
Financial information may be collected in order to make arrangements for the payment of dental services. We collect information from our patients about their health history, their family health history, physical condition, and dental treatments. (Collectively referred to as “Medical Information”.) Patients’ Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.
Patients’ Medical Information is disclosed for the following purposes:
To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf
To other dentists and dental specialists where we are seeking a second opinion and the patient has consented to us obtaining the second opinion
To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment
To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion
To other health care professionals, such as physicians, if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment
If we are ever considering selling all or part of our dental practice, qualified, potential purchasers may be granted access, as part of the due diligence process, to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.
Dentists are regulated by the Alberta Dental Association and College, which may inspect our records and interview our staff as part of its regulatory activities in the public interest.
Today's Date
Do you have insurance? YesNo
Name of insured:
Date of Birth:
Employer:
Name of insurance Co:
Policy#
ID#
Div#
Do you have a secondary insurance plan? YesNo
LifePath Dental & Wellness is pleased to offer you the following payment options.
Option 1: Payment is due in full the day treatment is rendered. We accept cash, cheque, debit, Visa, MasterCard, American Express, and E-transfers (accounts@lifepathwellness.com)
Option 2: Your insurance company may require you to, or you may prefer to, pay for your dental work directly on your treatment day and have your insurance company reimburse you. LifePath Dental & Wellness will process your payment on the date treatment is rendered. Our team members will assist you in submitting the necessary documents to your insurance carrier.
Option 3: You may leave your credit card number on file, and we will directly bill your insurance company; you do not have to wait around on your treatment day. Once your insurance company has paid us their portion, our Financial Advisors will process your patient portion to the credit card on file and email you your receipts. LifePath Dental & Wellness will provide estimates when requested.
I have chosen as my payment option: Option 1Option 2Option 3
I, have chosen Option 3, and I hereby authorize and balances not covered by my insurance to automatically be applied to my credit card.
I have chosen Option 3, for the following family members and I hereby authorize any balances not covered by my insurance to automatically be applied to my credit card.
Print Name *
Date:
Patient Name
Patient's Date of Birth
This letter authorizes
to release a complete set of records, including my x-rays, chart notes and all other records or those of my minor child
to Chestermere Lifepath Wellness, Ltd. located at the above-noted address.
I represent that I have legal authority to authorize the release of records requested. I understand that the information in my/my minor child’s health record may include, but is not limited to, information related to my/my minor child’s physical, behavioral, or mental health conditions previously disclosed.
If you have questions about the disclosure of the requested records, please contact Chestermere Lifepath Wellness, Ltd. at (403) 235-6208.
This request is for my minor child YesNo
Call us at (403) 235-6208 to book your New Dental Patient Consultation with us today!
We serve the areas of Chestermere, Rainbow Falls, East Chestermere, Kinniburgh, The Cove, Calgary, SE Calgary, NE Calgary, Easthills, Langdon, Gleichen, Indus, Carseland, Bassano, Strathmore, Brooks, Suffield, Medicine Hat, Drumheller and surrounding areas.
We are proud to offer convenient and free parking for our patients.
