Forms And Insurance Information
For New Patients

New Patients:
Please fill out the two forms below prior to your first visit and either
email it to us or bring it to your appointment.

Please also see below important information you should know about your dental insurance,
and please have the information ready for us at your first appointment:

Information required to submit your claims electronically :

  • Name of insurance provider / carrier

  • Plan holder's name

  • Plan holder's date of birth

  • Plan holder's address

  • Group / policy number

  • Certificate / plan ID

Information you should ask your insurance company regarding your coverage :

  • Please note that payments are due in full on the day of the appointment. Our office does not accept direct billing to the insurance company,, unless you are on the Canadian Dental Care Plan (CDCP).

  • What is the annual maximum amount allowed per person for major / minor treatment ?

  • What is the co-pay percentage for major / minor treatment ?

  • What is the annual deductible ( if any ) ?

  • Is the coverage based on a calendar year or on a rolling month (6 months, 12 months, etc) ?

  • How many units of scaling and/or root planing are covered per year or per x rolling months ? Does the policy allow additional units ?

  • What is the allowable frequency for recall exams (typically every 9 months), polish and fluoride (normally 6 months for minors, 9 months for adults) ? Note that this frequency is independent of the scaling frequency.

New Patient Information Form
Patient Records Release Form

If you are on the Canadian Dental Care Plan (CDCP),
please also fill out and sign the following CDCP consent form.
We will not be able to send estimates and start treatment planning until we receive this form.

CDCP Consent Form

Contact Us

Address
Suite 101, 1897 Baseline Road, Ottawa, ON K2C 0C7

Phone:
613-723-7872

Email:
reception@tangerinefamilydentistry.com

Hours:
Mondays: 8:00 A.M. - 6:00 P.M.
Tuesdays: 8:00 A.M. - 6:00 P.M.
Wednesdays: 8:00 A.M. - 5:00 P.M.
Thursdays: 8:00 A.M. - 5:00 P.M.
Fridays: As needed
Saturdays, Sundays: Closed

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