Patient Consent Form


Patient Consent Form

Please provide details For this Patient Consent Form

  • Permission to collect, use and disclose personal information.

  • Contact information is/may be disclosed to a third party health benefit provider or insurance company when submitting a claim on the patients’ behalf, for payment or reimbursement of all or part of the cost of the treatment provided, or when a patient has requested a preauthorization of a proposed treatment.

    By signing this Consent Form you agree that you have provided your personal information. You consent to the collection, use and disclosure of the information for the appropriate purposes listed above. Your information may be accessed by the College of Denturists or other regulatory authorities acting under statute of a legal issue. We will seek your approval, in advance, if a new purpose should arise for the use and/or disclosure. You may withdraw your consent for the use and disclosure of your personal information at any time. We will explain the process and the ramifications of your decision to do so.

Testimonials

What Smile Denture & Implant Customers Are Saying

Excellent service. Got an appointment on short notice for urgent service. Rapid and efficient. Very helpful in explaining repair to be done on dentures. I definitely recommend this clinic.
Joanne Laflamme
Joanne Laflamme
My husband's denture broke and we were from out of province. Caner saw him within an hour and had his repair done same day. The staff (especially Caner) was friendly, professional and knowledgeable. The repair was excellent! I would recommend this clinic to anyone.
Noah Martinez
Noah Martinez
I was having terrible trouble with my bottom denture. Caner explained how he was going to fix it, he did within the week and now, holy moly, I can eat again. Fantastic!
Mick Pates
Mick Pates
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