Dental Treatment Informed Consent Form

Dental Care Consent Form

In-home clinical assessment and prosthodontic care
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
Any Pets?
Breed and Name of pet(s)
POA Information

Substitute Decision Maker
POA *

First & Last NameRelationship
Email*
example@example.com
Cell Phone Number*
Direct Contact Format: (000) 000-0000.
Denture Visit

Choose Type
Initial Denture AppointmentDental Cleaning 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.
Any allergies or sensitivities
Latex, fragrance etc.
To best support you during your visit - Please share your Questions/Concerns *
Dental team is happy to answer at next visit
Private Insurance PlanGovernment Insurance PlanUninsuredVeterans Insurance PlanNIHB Program (First Nations & Inuit)
Insurance Number*
CDCP or other
Acknowledgment and Waiver
I allow and authorize 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 Denture Ready which involves post-treatment and follow-ups.I give my consent to Denture Ready to take photos and/or videos for use in our online gallery and/or social media.I understand 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*

re-submit signature
To ensure the highest standard of care, all initial appointments include a required comprehensive oral examination in accordance with Ontario Denturism Standards.

This appointment includes:

• Evaluation for proper denture fit, function, and comfort

• Screening for any abnormalities or conditions that may require referral

• A personalized/private discussion with treatment options and expectations

• Travel time and mobile service convenience (In-home or care facility visit)

• Professional recommendations and treatment planning tailored to your needs

*This thorough assessment is essential to provide safe, effective, and appropriate denture care. It ensures that any treatment moving forward is clinically sound and aligned with federal standards of practice.

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Payment Description
This secure payment link is provided for convenience. Payment submitted through this secure portal may include mobile service with your Ontario® Registered Denturist. Any remaining fees are collected at the patient appointment where a credit card terminal is available. Other forms of payment include cash, personal cheque or conveniently by

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Dental Care Consent Form

Patient Information

POA Information

Denture Visit

Acknowledgment and Waiver