1. Consent for Examination and Diagnostic Records

I consent to an oral examination and authorize Dentix24 Dental Clinic to take dental radiographs (x-rays), photographs, and other diagnostic records as deemed necessary for diagnosis, treatment planning, documentation, quality assurance, and legal record-keeping.

I understand that I may refuse or withdraw this consent at any time, subject to professional, ethical, and legal obligations.

2. Financial Responsibility, Insurance, and Late Payment

I understand that dental insurance is a contract between myself and my insurance provider. I acknowledge that insurance estimates are not a guarantee of payment.

I agree that I am financially responsible for all fees incurred, including any portion not paid by my dental benefit plan. I authorize Dentix24 to submit insurance claims electronically on my behalf where applicable.

For patients without dental insurance, payment in full is due on the date of service unless prior arrangements have been approved in writing.

Accounts with outstanding balances may be subject to administrative or collection fees and/or referred for collection if payment is not received within a reasonable period of time.

3. Appointment and Cancellation Policy

Appointment times are reserved exclusively for me. I understand that a minimum of two (2) business days’ notice is required to change or cancel an appointment.

Failure to provide adequate notice, or failure to attend a scheduled appointment, may result in a missed-appointment or cancellation fee.

4. Communication Consent

I authorize Dentix24 Dental Clinic to contact me regarding appointments and administrative matters via voicemail, email, and text message.

5. Privacy and Confidentiality

I acknowledge that my personal health information will be collected, used, and disclosed in accordance with applicable privacy legislation (PHIPA) and Dentix24 Dental Clinic’s privacy policies.

6. Third-Party Attendance and Minor Responsibility

If someone other than the parent(s) or legal guardian(s) listed below will accompany the patient to appointments, their name(s) must be provided.

I understand that accompanying individuals are not authorized to consent to treatment unless legally permitted or explicitly authorized in writing.

For minor patients, the parent or legal guardian signing below accepts full financial responsibility for all services rendered.