PLEASE NOTE: By signing and returning these forms to our office you are

committing to a surgical appointment. As we must schedule staff (medical

anesthetist/nurse) you understand that once an appointment is booked if
cancelled you will forfeit your $250 deposit.
General Anaesthetic Payment Information

A $250.00 NON-REFUNDABLE DEPOSIT is required at the time of booking in order to secure your
child’s appointment; you understand that once booked if cancelled, for any reason other then a
valid medica reason, INCLUDING FAILURE TO FOLLOW EATING AND DRINKING GUIDELINES; the
$250 deposit will not be returned.

Unless prior arrangements have been made with our office, the total cost of treatment, less
the deposit is due on the day of treatment. Payment will be processed to the credit card
listed below, unless otherwise specified.

On the day of surgery, if more treatment is required than what was originally estimated, you will be
required to pay the difference at the end of the appointment.

Once all treatment has been completed, the dental claims for the treatment will be sent to your insurance company
and we will direct them to reimburse you directly.

Your estimated balance owing is: $3367.00 (total 3617.00 minus deposit 250.00)
5160750017897393 07/25 331
Visa/MasterCard Card#____________________________________________ Exp. Date __________Validation# ______________

Devlin Chan
Card holder’s name: _____________________________________ Signature________________________________________________

Devlin Chan
I, _________________________________the father/mother/legal guardian of Isabelle Chan have reviewed the above
financial obligations, and I understand that it is my responsibility to read the package of information given to me in
regards to this appointment.

___________________________________________________________ ____________________________
Signature Date

Thank you
Dental Care 4 Kids
 Consent for Dental Treatment under General Anaesthesia

Patient’s Name: Isabelle Chan

I herby consent to dental treatment under general anaesthesia on the above named patient.

I understand that this dental treatment may include:

• Radiograph
• Cleaning of the teeth
• Preventive dental procedures (ex. pit & fissure sealants, fluoride treatment)
• Dental restorations
• Extractions of teeth

The anticipated effect and nature of such treatment has been explained to me by
Dr. Yu-Shu/Dr. Lynn Jacob.

I also consent to such additional treatment or operative procedures as in the opinion of

Dr. Yu-Shu Chiu/Dr. Lynn Jacob, is immediately necessary during the course of the above procedure,
and to the administration of general anaesthesia for this purpose.

COVID-19 Testing for Treatment under General Anaesthesia

As we are all aware, the global pandemic is a fluid situation. We have seen in Ontario that the cases of
COVID-19 have increased since the start of September. Peel Region is one of the regions that has an
increase in new cases. In light of this, Surgicentre Services (our anaesthesiologist team) has mandated
that your child have a COVID-19 test done 3-6 days prior to their dental surgery. Once the test is
completed, please practice strict social distancing until after their surgery. We understand that this test
may seem daunting to your family, but this is a safety measure for our staff, our patients and your family.

I have read this authorization and understand it, and give my consent to the above.

Devlin Chan
______________________________________________
Print name of Parent/Legal Guardian

_______________________________________________ ________________________________
Signature of Parent/Legal Guardian Date

Sarah Siu
_______________________________________________ _________________________________
Signature of Witness Date

_______________________________________________
Print Name of Witness