Office Policies & Patient Intake Form

Access the Patient Intake Form at the bottom of this page. 

Please review the following important office policies before completing the form.

Cancellation Policy

Simply Orthodontics is committed to providing quality care with respect for your time.  Because  your appointment time is reserved just for you it is important that you provide at least 48-hours of notice to cancel or reschedule any appointment in our office.

You may reschedule or cancel an appointment by calling 780-765-7600 (you may leave a detailed message if you reach us outside of office hours), or by emailing

Simply Orthodontics reserves the right to charge a cancellation fee of $50 for cancellations or changes made with less than 48-hours of notice and/or to require pre-payment to reschedule a no-show appointment. 

Understanding Your Orthodontic Insurance

To avoid delays for you, it is important that you call your dental insurance provider and inquire about your orthodontic coverage prior to your first appointment.  With this information, we will be able to help you fully understand how your reimbursement will be structured.  

Questions to ask:
  -  Does my plan cover orthodontic treatment?
If Yes:
  -  At what percentage?
  - Is there a maximum amount that is covered per year, or a lifetime maximum?
  - If I pay-in-full at the start of treatment, do I get a full reimbursement at that time? If not, what do I need to do to get reimbursed?
  - Are there any limitations to my coverage (age of the patient, other)?
  - What do I do if I have two insurance policies?

Use of Personal Information Policy

Simply Orthodontics is committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner.

Contact Information is collected from our patients, and includes information such as names, home addresses, work information, telephone numbers and email addresses.  Your health information is protected under the Health Information Act of Alberta (HIA). We collect your health information for purposes authorized by section 20 of the Health Information Act to support us in:

  • providing treatment and care;

  • verifying your eligibility for health services;

  • conducting investigations or reviews;

  • conducting research following ethics review;

  • providing health services provider education;

  • carrying out internal management, including obtaining and processing payment;

  • as expressly authorized by law in Alberta or Canada.

Except in special family or emergency circumstances or were required or authorized by law in Alberta or Canada, we ask for your consent before we disclose your health information to anyone not responsible for providing your treatment and care. For more information, please contact our Privacy Officer at 780-756-7600, our office at 10150-150 street, Edmonton, T5P 1P1.

Financial information may be collected in order to make arrangements for the payment of orthodontic services.  Financial information is not disclosed without your prior explicit consent.

Medical Information is collected and used for the purpose of diagnosing oral health conditions and providing orthodontic treatment and appropriate oral health advice.  Medical information includes information about your health history, physical condition, and dental history.

Patients’ Medical Information is disclosed:

  - To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment, or has asked us to submit paperwork on the patient’s behalf.
  - To other dentists, dental specialists or healthcare providers, where we are seeking an opinion and the patient has consented to us obtaining the opinion.
  - To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment.
  - To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide an opinion.
  - To other healthcare professionals such as physicians if the patient, with their consent, has been referred by us to the other health care professional for either an opinion or treatment.

Dental records are used to assess and monitor dental health, condition, growth and development. Dental records include radiographs, photographs, clinical findings and dental history.  Dental records may be anonymously disclosed to other dental professionals and healthcare providers for the purposes of professional teaching and learning.

Dental Specialists in Alberta are regulated by the Alberta Dental Association and College which may inspect our records and interview our staff as part of its regulatory activities in the public interest.