Our Office Policies

Cancellation:
The appointments are reserved time for you only. A minimum notice of two business days is required to avoid possible cancellation fees.
Payment:
Full payment is required at the time of each appointment. We accept cash, debit, VISA and MasterCard. HST is not charged. If you have any insurance benefits, they will only be assigned to you. You will pay us in full and we will send your insurance on your behalf electronically or manually in some cases.
Insurances:
Co-payment is required at the time of each appointment as well as any deductibles or fee guide differences that may arise. As everyone’s insurance details are unique it is not possible for us to be accountable for knowing all of the details pertaining to your specific plans coverage. As a courtesy, we will be more than happy to assist you with the processing of your dental claims, either electronically or manually on your behalf. We will not waive any insurance fees under any circumstances.
Privacy:
According to the Privacy Policy Act (PIPEDA), Dr. Safari & Associates is to withhold all patient information and acknowledge it as strictly confidential. Patient authorizations/signatures are required prior to the release of any information to a third party other than a collection agency.
I have read and understood the policies listed above.
Patient Name:(Required)

Once fully read and reviewed, please make sure that the above document is filled out appropriately. By signing below and submitting this document, we are assuming that it has been read in its entirety. All patient signatures will be verified for authenticity in the office.

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