DENTURE PATIENT REFERRAL FORM - FOR REFERRING PROFESSIONALS

  • For Dental Professionals sending referrals to Ottawa Valley Denture Clinic.

  • In order to send a referral, please use the Denture Patient Referral Form.


NEW PATIENT INTAKE FORM

  • All new patients, please complete a New Patient Intake form.

  • If you do not have an appointment booked, contact the office to schedule your appointment.


PATIENT AUTHORIZATION FORM

  • This Patient Authorization Form is to authorize the clinic to release information to select care givers or family members such as your spouse, significant other, parents or children.

  • Please complete this form to let the clinic know who they may contact regarding your treatment and upcoming appointments.


COVID-19 SCREENING & CONSENT

  • This Covid-19 Screening & Consent form is to be completed before every visit to the the clinic.

Ottawa Valley Denture Clinic
186 Pembroke Street West,
2nd Floor
Pembroke, ON K8A 5M8

613-735-4034
[email protected]