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 / Zip Code

City
Entry 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 ConsultationBookingVideo/CallAnnual recallOther
Do you have any medical conditions that we should be aware of? (specific impairment, mobility circumstance, advanced dementia etc.)
If yes, please specify in the field above.
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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Opportunity to ask questions:
You can ask any questions and we're happy to discuss your oral hygiene and health concerns:

* Visit to learn more: Website🌐 (dentureready.com)

* Payment option by credit card 💳 Pay here creditcard

* Conveniently by cash, EMT: suzanne.salga.dentures@gmail.com, personal cheque, and more.

*⏹️A Square Payment terminal is available at ever appointment.

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* Email: info@dentureready.com or phone (647)204-4478 for a 15 minute complimentary consultation or video call.

Where can I Apply for CDCP Canadian Dental Care Plan:

APPLY TO FEDERAL DENTAL PROGRAM
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Dental Care Consent Form

Patient Information

POA Information

Denture Visit

Acknowledgment and Waiver