Intake

First name required
Last name required
Day required
Month required
Year required
Valid phone number required
(403-555-5555).
Street required
City required
Select province
Postal code required
Name required
Contact number required

The above information is true to the best of my knowledge. I understand that I am financially responsbile for any balance on my account. I also authorize Beacon Hill Dental or insurance company to release any information required to process my claims. I understand that my account will be charged $50.00 per hour for any missed appointments or any appointments cancelled with less than 2 business days notice.

Required

Please answer the following questions to the best of your ability. This information is confidential.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect infomation can be dangerous to my (or patient's) health. It is my responsibility to inform Beacon Hill Dental of any changes in medical status. I consent to the performing of the dental and oral procedures agreed to be necessary or advisable, including the use of general anesthetic or local anesthetic or any drugs as indicated.

Please review your dental plan very carefully to ensure you understand the exclusions and limitations of your plan. If your dental plan does not cover the full cost of treatment, you will be resonsible for any difference between the amount paid by your dental plan and the amount charged for your treatment.

Required

We are pleased to announce that Beacon Hill Dental follows the new 2024 Alberta Dental Fee Guide. Read more.