Seniors New Patient

Client Information

Emergency Contact

Personal Directive Agent (Power of Attorney)

Facility Information

Insurance Information

Medical Information

Oral Exam Consent

This information is to ensure that you are aware of the option to receive an oral health exam by a registered dental hygienist within your facility. an oral exam for patient named above for which a fee of $0, in which the dental hygienist will do a full assessment. This includes a visual oral cancer screening, hard deposits (calculus/tartar), inflammation (gingivitis & periodontitis), infection (periodontal & tooth), cracks, and dental decay (cavities/caries). Treatment planning will follow, and treatment suggested must be approved with the Guardian (Power of Attorney) before further treatment or charges.

This release also acknowledges that on this date at least two options for treatment offered:

Medical Information & Power of Attorney Consent

Option to release medical information & Power of Attorney to Divine Dental Hygiene to receive an oral health exam and/or dental hygiene treatment by this registered dental hygienist within the facility. Divine Dental Hygiene has a Privacy Information Assessment approved under the Officer of Information and Privacy Commissioner of Alberta (OIPC of Alberta PIA #022618). Release of medical information & Power of Attorney for the above patient to Divine Dental Hygiene to complete an oral health exam and/or treatment in this facility.

This release also acknowledges that on this date at least two options offered to you:

Dental Hygiene Consent

This information is to ensure that you are aware of the existing periodontal disease (gum disease) and infection present in your mouth. It is to acknowledge that you have been informed of the existence of this disease and given a copy of the periodontal pocket charting. The consequence of non-treatment will likely result in a progression of this infection and, if it continues, eventual bone loss, loosening of teeth and the ultimate loss of teeth.

This release also acknowledges that on this date, you are consenting to "nonsurgical approach" to periodontal disease.

Initial fees for a cleaning can range from $ 144 for 2 units of scaling to $ 381 for 4 units scaling, polish, fluoride. If the estimate needs to be increased, another treatment consent form will be offered to you before further treatment.

Future frequency of every 6 months for periodontal dental cleaning of $ 216 for 3 units scaling are suggested and will be discussed after initial treatment.

This release also acknowledges that on this date at least two options offered to you:

X-ray Consent