In order to adequately deliver dental home care services suitable for you or your loved one, please complete the following forms. These forms will allow us to better address your dental needs and will help us to be efficient when we visit you at home. We always require your consent prior to beginning any treatment, including dental examinations and complete dental services in order to determine best clinical practices. We will also require your consent to collect personal information as part of documentation procedures and treatment planning. Your personal and health information will never be disclosed outside of treatment protocols. For your protection, we always keep your personal and health information confidential in compliance with the Personal Health Information Protection Act. Please review our Privacy Policy to learn about how your information is used during treatment procedures.
 
Please complete these forms and fax them to our office at (905) 237-8522. If you do not have a fax please contact our office and we will assist you with completing the forms over the phone.
Form 1: Consent Form

 

Consent to collect personal and health information forms a crucially important component of your overall treatment between you and our dental care provider. In order to better understand your dental concerns we need to collect information relating to your symptoms, current prescription medications, medical history, dental history and any past or recent hospitalization. Before any dental treatment will take place, our dental care provider will explain all the steps of the procedure, including your options, benefits, risks, costs and post-operative instructions to ensure that you fully understand what to expect. Please read the Consent Form to understand how this information is used as part of your dental treatment. If you have any questions or concerns feel free to contact our office.

 

Download Form 1

Form 2: Screening Form

 

This form includes your personal contact information, medical history, dental history, allergies, and medications list. If you are a Power of Attorney (POA) or a Substitute Decision Maker (SDM) acting on behalf of someone, your contact information is important to ensure open lines of communication and treatment decisions. The screening form helps us understand your current medical condition and how to best manage your treatment options, including your present dental concerns. We pay particular attention to senior patients who are diabetic, have specific allergies, heart conditions, and/or who have recently experienced a heart attack or stroke, as this information will help us make your in home dental visit more comfortable for you or your loved one.

 

Download Form 2

Form 3: Insurance Information

 

If you have dental insurance benefits, mobile dental care services are covered under most insurance plans. Our mobile denture clinic services and mobile house call dental cleaning services are covered by Ontario Disability Support Program (ODSP), Ontario Works (OW), Non-Insured Health Benefits for Inuits (NHIB), Veteran Affairs Canada (VAC) and private insurance plans. If you have your policy plan number and subscriber ID as provided by your insurance company, please fill the details in this form. We will work with you to ensure all the details are collected and that you are reimbursed for our mobile dental care services. We also accept other forms of payment, including VISA, Mastercard, cash, and personal cheques. Please feel free to contact our office about your payment options.

 

Download Form 3