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Step 1 of 4 - Patient Information
Please complete all information to the best of your knowledge. If not applicable, mark it as N/A.
Questions marked with a* are required. Questions you are unsure of or would prefer to answer verbally can be skipped.
If you do not know the exact date of dental visits or the age of your dentures, provide an estimated timeline.
If you have or wear dentures, please answer the questions below. If you do not have dentures or have never worn dentures, please write N/A.
I consent to have treatment by my denturist at Ottawa Valley Denture Clinic (OVDC).
I consent to have my dentist or physician contacted if additional dental/medical information is required for my dental care.
I understand that this clinic does not accept assignment of benefits, and OVDC will not submit to or claim from insurance companies. Any claim forms will be printed off and provided to the patient at the completion of service.
I assume responsibility for all fees incurred. All fees not covered by my insurance company is my responsibility.
We understand that circumstances change and we ask to be notified at least 24 hours in advance. This allows us to manage our schedule effectively and offer the time slot to another patient in need. Failing to show up for your scheduled appointment without prior notice will result in a fee of $75. We appreciate your understanding and cooperation in ensuring we can provide timely and efficient care to yourself and all our patients. Please note we consider exceptions for unavoidable emergencies on a case-by-case basis.
Many of our patients choose to have family members, such as spouses, significant others, parents, or children, contact us to inquire about treatment plans, procedure codes, and financial information.
Additionally, family members and caregivers may assist with booking, rescheduling, or canceling appointments. However, in compliance with the Personal Health Information Protection Act (PHIPA), we are unable to share this information with anyone without your explicit consent. If you would like to grant access to family members or caregivers for these purposes, please complete and sign this form.
You have the right to revoke this consent in writing, except where we have already made disclosures based on your prior consent.
To ensure that we can confirm your appointments and provide important updates regarding your appointments, treatment plan, or care, our office may need to leave messages. If we are unable to reachyou directly by phone, please indicate your preferences below:
613-735-4034[email protected]