New Patient Forms

1. A valid credit card will be required at your appointment and MUST remain on file. It is your responsibility to notify Bayside Dental and Orthodontics of any change which affects your credit card account. - Expiry date, change of account number, etc.

2. Your account must remain in “Good Standing” – any account with an outstanding or uncollected balance for more than 60 days will no longer be considered eligible for Direct Billing. You will then be responsible for full account balances and all fees must be paid in full at time of treatment for all future appointments. You will be notified in writing of the change to your account status if the privilege of Direct Billing has been revoked.

3. I have read this document in full and consent to the following financial agreement:

4. I, authorize Bayside Dental and Orthodontics to keep my signature on file and charge my credit card for any outstanding balance after 30 days of service. I will be notified by phone or mail if this amount is more than $200. A receipt for this transaction will be mailed, along with a statement of my account. Any lack of adherence to these terms will result in a loss of this direct billing benefit.

1. A valid credit card will be required at your appointment and MUST remain on file. It is your responsibility to notify Bayside Dental and Orthodontics of any change which affects your credit card account. - Expiry date, change of account number, etc.

2. Your account must remain in “Good Standing” – any account with an outstanding or uncollected balance for more than 60 days will no longer be considered eligible for Direct Billing. You will then be responsible for full account balances and all fees must be paid in full at time of treatment for all future appointments. You will be notified in writing of the change to your account status if the privilege of Direct Billing has been revoked.

3. I have read this document in full and consent to the following financial agreement:

4. I, authorize Bayside Dental and Orthodontics to keep my signature on file and charge my credit card for any outstanding balance after 30 days of service. I will be notified by phone or mail if this amount is more than $200. A receipt for this transaction will be mailed, along with a statement of my account. Any lack of adherence to these terms will result in a loss of this direct billing benefit.

1. A valid credit card will be required at your appointment and MUST remain on file. It is your responsibility to notify Bayside Dental and Orthodontics of any change which affects your credit card account. - Expiry date, change of account number, etc.

2. Your account must remain in “Good Standing” – any account with an outstanding or uncollected balance for more than 60 days will no longer be considered eligible for Direct Billing. You will then be responsible for full account balances and all fees must be paid in full at time of treatment for all future appointments. You will be notified in writing of the change to your account status if the privilege of Direct Billing has been revoked.

3. I have read this document in full and consent to the following financial agreement:

4. I, authorize Bayside Dental and Orthodontics to keep my signature on file and charge my credit card for any outstanding balance after 30 days of service. I will be notified by phone or mail if this amount is more than $200. A receipt for this transaction will be mailed, along with a statement of my account. Any lack of adherence to these terms will result in a loss of this direct billing benefit.