✅MOBILE DENTURE - INITIAL CONSENT FORM

Dental Care Consent Form

In-home clinical dental care assessment
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 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.
Patient Information

Please complete form
Name of Patient

First nameLast name
Date of Birth

MonthDayYear
MM-DD-YY
Address

Street Address

Name of Facility

Facility / Floor / Room # / Entry CodePostal Code

City
Any pet(s) during visit?
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.
Dental Visit

Choose Type
Type of Dental Visit
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/Chief Concerns
Dental team is happy to answer at next visit
Direct billing to all major insurance
Insurance Company & Number
CDCP or other
Acknowledgment and Waiver
Please check all below:
Initials
Appointment Request

▶ Appointment request date/time requires office approval
*** If an earlier appointment becomes available due to a cancellation, would you like to be contacted?
Signature

re-submit signature
Payment

Secure Appointment Request

Select and Reserve Below

📆 Book Your Comprehensive Oral Examination & Mobile Visit

This appointment includes:

✓ Ontario Registered Denturist

✓ Evaluation for proper denture fit, function, and comfort

✓ Screening for any abnormalities or conditions that may require referral

✓A personalized 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

* Tax included. No hidden additional fees

$175.00 CAD Quantity

Credit Card

Visit to learn more 🌐 www.dentureready.com
Should be Empty:

Dental Care Consent Form

Patient Information

POA Information

Dental Visit

Acknowledgment and Waiver

Appointment Request

Payment

Select and Reserve Below

Credit Card