Consent Form

1
Are you completing a consent form for an individual or multiple people (ex. a family or multiple children)?* This field is required.
an individual
multiple people
2
Name of client* This field is required.
First Name
Last Name
3
Date of Birth* This field is required.If client is under 12 yrs old or younger, please remember to bring in MCP card!
Date
Month
Day
Year
4
Please tell us the names and birthdates of the people you are booking for.If you're filling out this form for an individual and have already entered your name and date of birth, please skip!
5
Phone Number
Area Code
Phone Number
6
Email
example@example.com
7
What's the best way to reach you?
text
phone call
email
8
AddressPlease skip if you are an existing client and your address has not changed.
Street Address
Street Address Line 2
City
Province
Postal Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Is client under 18 years?* This field is required.
Yes
No
10
Parent/Guardian Name
First Name
Last Name
11
Primary Phone Number
Area Code
Phone Number
12
Our short notice cancellation policy.* This field is required.Please check the box to confirm you have read our short notice cancellation policy.
Our goal is to provide quality preventive dental care to all our clients in a timely manner. No-shows, late arrivals and cancellations negatively affect our clients and staff. We kindly ask that you cancel your appointment at least 24 hours in advanced. Failing to show or cancelling an appointment with less that 24 hours notice will result in a $50 fee (unless related to sudden illness or COVID-19 like symptoms). If you arrive more than 15 minutes late, we may need to reschedule your appointment.
13
Do you have dental insurance?* This field is required.If yes, please have your information on hand.
YESNO
14
Our direct billing policy.* This field is required.We are able to submit claims electronically to many different providers including Canada Life, Blue Cross, Johnson, Green Shield and more. You are responsible for paying for any portion of your treatment that is not covered by your policy. If you have coverage through Manulife or Sunlife (or another company that doesn't offer direct billing to dental hygienists) we require payment upfront and you'll get reimbursed directly from your insurance provider. We'll even send in your paper work so that you don't have to do anything with it! Please note: it can take 3-4 weeks for you to get reimbursed as we have to send forms via letter mail (this is the only way to process the claim). We recommend signing up for direct deposit with your insurance provider to reduce wait time as there may be mail delays due to COVID-19. We apologize for any inconvenience this may cause and if paying up front prevents you from accessing care, please let us know.
I agree and understand the policy.
I do not have insurance coverage.
15
Insurance companyPlease skip if we have your current information on file.
Great West Life, Sun Life, etc.
16
Group numberPlease skip if we have your current information on file.
17
Policy numberPlease skip if we have your current information on file.
18
If this is a group plan, what's the name of the employer that it's from (ex. Government of NL, NLTA, Verafin)?
19
If this policy belongs to someone other than yourself, we'll need to know their full name, date of birth and address.
20
Name of your medical doctor? (if none, leave blank)If booking for multiple people, please specify for each. We'll never contact your medical provider without your permission.
21
Name/location of the clinic? (If not applicable, leave blank)If booking for multiple people, please specify for each.
22
Do you have any medical conditions such as (but not limited to) cancer, heart/lung disease, diabetes, mental illness, etc. Please be as detailed as you can so that we can provide you the highest level of care possible. Omitting health conditions can have a negative impact on your oral health outcomes. If booking for multiple people, please specify for each.
If yes, then please specify it on the field above.
23
Are you currently taking any medications?If booking for multiple people, please specify for each.
If yes, then please specify it on the field above.
24
Do you have any allergies?If booking for multiple people, please specify for each.
If yes, then please specify it on the field above.
25
Have you even been told that you need take antibiotics before dental treatment?* This field is required.Usually associated with a rare heart condition.
No.
Yes.
26
Do you have a dentist that you see regularly? If so, do you know the doctor’s name?
27
Name of the clinic?
28
How long since your last check up?If booking for multiple people, please specify for each.
29
How long since your last dental cleaning?If booking for multiple people, please specify for each.
30
Do you have dental anxiety?
Yes
No
31
Is there anything about you'd like us to know ahead of time?
32
Please check the boxes if you understand and agree with these statements.* This field is required.
I understand that I always have the right to refuse recommended treatments.
I give consent to have dental hygiene services completed by a registered dental hygienist at the Dental Hygiene Studio.
I understand that the Dental Hygiene Studio is an independent dental hygiene clinic and that I should see dentist regularly for exams, xrays and treatment as required.
33
Client/Parent/Guardian Signature* This field is required.
Clear
34
Today's date.
Date
Month
Day
Year
35
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