SmilesInc | Registration Form

Registration Form

Thank you for choosing Smiles Inc. Our team is committed to providing you with the best possible care in a comfortable and professional manner. It is important that you are aware of a few office policies so that our relationship remains a positive one. Please read the following information carefully, and ask any questions that you may have.

REGISTRATION: Please complete the Medical History form on this page before your initial visit. When you arrive for your appointment please inform the staff of any changes in your medical history, and any additional medications you may take, or changes in personal information.
DIRECTIONS: We are located at 12, Dundonald Street West in Hamilton, in the former Olympic Club gym building. Dundonald Street runs in front of Masters Ltd. Our website has a google map.
PARKING: There are a few parking spaces available on Dundonald Street for one hour, (there is always bike parking available). However, we do not guarantee they will be available so please give yourself enough time to get here and park. Bulls Head carpark always has spaces.
E-MAIL REMINDERS: We use Smile Reminder System as a way of confirming appointments, please contact us to confirm. A call will be made if no email is available. We do ask that appointments are confirmed 24 hours in advance. Late cancellations (less than 24 hours) or a missed appointment fee of $100 will be charged.
APPOINTMENTS: We schedule our appointments to be as efficient as possible. Please try to be on time for your scheduled appointment. If you are late, it may be necessary to reschedule that appointment to another time and you will be charged the late cancellation fee.
TO CHANGE AN APPOINTMENT: If you need to change an appointment, please do so with as much notice as possible, ideally at least 48 hours in advance.
PAYMENTS: The patient portion (co-pay) is collected at the time of service, and the amount due depends on your Insurance benefits. We accept cash, cheques, debit and credit cards, but not American Express. Payment can also be made online to BNTB 20 006 060 266298100 (please place the name of the patient in the beneficiary note section).
CONFIDENTIALITY : Health regulations stipulates that there should be no photography /videography within a healthcare facility; which includes snapchat, facebook, whattsapp and all other social media.
INSURANCE : We will assign payment to your insurance company, but any unpaid balance is your responsibility. And any payments received from your insurance should be returned to Smilesinc. All unpaid accounts are sent to Bermuda Credit Association.
NO INSURANCE: If no insurance details are provided, or you change policy mid treatment you will be FULLY responsible for all treatment balances.
K.E.M.H. APPOINTMENTS: Where possible, these appointments require one week cancellation notice. There is a missed appointment fee for these appointment cancellations without proper notice.

I have read and understand the above office policies, and agree to abide by them. *

NAME:*

Middle Name

Last Name*

MAILING ADDRESS*

DATE OF BIRTH*

CONTACT INFORMATION

Home Phone

Work Phone

Cell Phone*

Email*

EMERGENCY CONTACT PERSON

Name*

Relationship*

Example label

CELL/WORK*

Work and Insurance Details

NAME OF EMPLOYER*

DENTAL INSURANCE?*

Yes

IF YES, PLEASE SELECT ONE

IF NO DENTAL INSURANCE – I AM FULLY RESPONSIBLE FOR ANY TREATMENT BALANCE

I, the undersigned, certify that I (or my dependent) have insurance benefits with my insurance company, and when warranted, assign directly to Smiles Inc. I understand that I am financially responsible for all charges not paid by insurance, and that all unpaid accounts are sent to Bermuda Credit Association. I hereby authorize Smiles Inc. to release all information necessary to secure payment of benefits. I also authorize the use of this signature on all insurance submissions. *

Date*