Dental Treatment Informed Consent Form

Dental Care Consent Form

Mobile Dental Services
Patient Information

Please complete form
Name of Patient*

First nameLast name
Date of Birth*

MonthDayYear
MM-DD-YY
Address*

Street Address

Name of Facility

Room # / FloorPostal Code

City
Entry Buzzer / Code to Floor / Building / Elevator
Enter codes separate with a comma
POA Information

Substitute Decision Maker
POA

First & Last NameRelationship
Email
example@example.com
Cell Phone Number*
Direct Contact
Denture Visit

Choose Type
Type of Dental Visit*

Initial ConsultationBooking AppointmentAnnual recallVirtual CallOther
Do you have any medical conditions, mobility limitations, specific impairment, other circumstance, advanced dementia that may affect your appointment?
If yes, please specify in the field above.
To best support you during your visit - Please share your Questions/Concerns
Dental team is happy to answer at next visit
Direct billing to all major insurance*

Private Insurance PlanGovernment Insurance PlanUninsuredVeterans Insurance Plan
Insurance Number
CDCP or other
Acknowledgment and Waiver
Please check all below:*

I allow and authorize (Mobile Denturist & Denture Ready) to perform this procedure to me. The denturist explained the nature of the treatment and my denture limitations.I understand that I appoint a family member or PSW present to facilitate/translate, relay instructions during my appointment(s).I understand that I will be contacted by a Denturist which involves post-treatment and follow-ups.I give my consent to Denture Ready to take photos for educational and/or may be used online clinical website gallery.I understand that and agree that I am responsible for the fees associated with the treatment(s). My initial appointment fee is non refundable.I have read & acknowledge that all information I provided in this form is true and accurate.
Initials*
Appointment Request Date and Time Requires office approval
Signature*

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Website🌐 (www.dentureready.com)

Credit Card Portal:

1. * Balance Statement Payment 🔗Secure Payment Portal

2. * Initial Visit 🔗Secure Payment Portal

Payment Description
This secure payment link is provided for convenience. Payment submitted through this secure portal may include mobile service with a licensed dental provider. Any remaining fees are collected at the patient appointment where a credit card terminal conveniently available.Conveniently by cash, personal cheque or EMT:✉️ suzanne.salga.dentures@gmail.com

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To best support you :

*Send us a message🔗 Questions? We've got answers

* COntact Email: info@dentureready.com or phone 📞(647)204-4478

Virtual call available : 🔗HERE

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Government Co-payment Eligability - Canadian Dental Care Plan (CDCP)

🔗 APPLY TO FEDERAL DENTAL PROGRAM
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Dental Care Consent Form

Patient Information

POA Information

Denture Visit

Acknowledgment and Waiver