HELP Dental Recertification Form

Who is this form for? 

This form is for current HELP Dental Clinic patients who need to recertify their information with the clinic to retain eligibility. 

If you need to apply to become a patient, please use the New Patient Application. 

 

What information will you need?

In order to complete the recertification process, we will need updated information on your income. If other factors have changed, such as the number of people or earners in your household, your address, or living situation, we will also need updated information to document those changes. 

I agree to abide by the following responsibilities and conditions:

PATIENT RESPONSIBILITY

Clinic:

• I will update any changes in household income, address, phone number, or other personal information in a timely manner.
• I understand my responsibility to remain in good standing by applying every 12 months with current documents.  If my coverage lapses, I understand that medications and treatment will not take place until I re-enroll.
• I will always be respectful to staff/providers/specialists/volunteers. HELP will not tolerate disrespectful or rude behaviour toward any staff or volunteer, including specialists and their staff to which patients may be referred. 
• I will cancel appointments at least two business days prior to the scheduled appointment. I understand that cancelling an appointment within two business days will result in an additional $25 charge to cover the cost of the missed visit. 
• If I am suspected to be under the influence of alcohol or drugs, I will be asked to reschedule my appointment.
• I will be required to refrain from the use of electrions (cell phones, etc.) while receiving treatment.

BY SIGNING BELOW, I CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION TO THE BEST OF MY KNOWLEDGE.

I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BY DANGEROUS TO MY HEALTH.