Alternately, the form can be filled online below
I, understand, certify that I (or my dependent) have insurance coverage and assign directly to Drs. Bishara - Margolian DPC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for
all charges whether or not paid by insurance. I hereby authorize Drs. Bishara - Margolian to release all information necessary
to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
* All fees or balances not covered by your dental insurance policy will be payable at time of visit. You must provide us with all
insurance information. We do not have access to your private insurance policy information unless provided to us.
I certify that I have read, understood and accurately completed the personal, medical and dental histories to the best of my
knowledge and have not knowingly omitted any information. If required, I consent to my physician being contacted regarding any specific medical
questions. I authorize Drs. Bishara - Margolian and their staff to perform necessary diagnostic procedures and treatment as required to
achieve a proper level of dental care.
Please select the Circle and click the SUBMIT button
We are looking forward to hearing from you.
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Margolian Dentistry, 1750 Dundas Street East,
Whitby, Ontario, L1N2K8, Canada
Phone : 905-436-2400
Email : email@example.com
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