We are pleased to offer you a variety of payment options. Please check which you would like to participate in:

Estimates of treatment will be provided upon request and pre-authorizations sent to your insurance company for approval. Services and fees may vary during treatment due to unforeseen factors. Every effort will be made to update the patient but a new written estimate may not be provided. The account holder is ultimately responsible for full payment and accuracy of insurance information.

West Calgary Dental adheres to legislation in the Alberta Health Information Act to keep your personal information private, including credit card authorization.

Please sign below to acknowledge that you have read and understand:

We protect the privacy of our patient's personal information and utilize all personal information in a responsible and professional manner. This document summanzes some of the personal information that we collect, use and disclose. In addition to the circumstances described 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 and work telephone numbers (collectively referred to a "Contact Information"). Contact information is collected and used for the following purposes:

1. to open and update patient files
2. to invoice patients for dental seNices, to process credit card payments, or to collect unpaid accounts
3. to process claims for payment from third-party health benefit providers and insurance companies on the patients behalf

Contact information is disclosed to third party health benefit providers and insurance companies where the patient has asked the office to submit a claim on their behalf.

Financial information may also be collected in order to make arrangements for the payment of dental seNices.

We collect information from our patients about their health history, their family health history, physical condition and past medical and dental treatments (collectively referred to as "Medical Information"). Patients' medical information is collected and used for the purpose of diagnosing dental conditions and to provide treatments.

Patients' medical information is disclosed:

1. to third party health benefits providers and insurance companies where the patient has requested the office submit a claim for reimbursement of all or part of the cost of dental treatment of their behalf
2. to other dentists and dental specialists, where we are seeking a second opinion
3. 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
4. to other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion
5. to other health care professionals such as physicians if the patient, with their consent, has been referred by us to other health care professionals for either a opinion or treatment

As a member-office of the Alberta Dental Association and College, and affiliated with the Alberta Health SeNices, our records may be inspected and our staff inteNiewed as part of their regulatory activities and in the public interest.