Online Forms

Consent Forms

Plain-language consents you can read and sign from home — treatment, privacy and communications, all in one pass.

Step 10%

Who is this consent for?

Patient first name

This field is required.

Patient last name

This field is required.

Date of birth

This field is required.

I am signing as

The patient (18+) Parent / legal guardian of the patient

Consent to examination & treatment

I consent to dental examination, diagnosis (including x-rays and photographs) and preventive care at Dentistry @ Manotick. I understand that before any specific treatment beyond examination and hygiene, the procedure, alternatives, risks and costs will be explained to me, and I may ask questions or decline. I understand no outcome can be guaranteed, and that I may withdraw consent at any time.

I agree to the consent to treatment *

Privacy & communications

I consent to the collection and use of my personal and health information to provide dental care, process insurance claims (including direct billing and the CDCP where applicable), and maintain my dental record, per the office Privacy Policy and applicable law. Information is shared only as needed for my care or as legally required.

I agree to the privacy consent *

May we contact you with appointment reminders and recall notices?

Yes — text, email or phone Phone calls only Email only No reminders please

Signature

Your electronic signature applies to all consents selected above.

Full name of person signing

This field is required.

Signature

Draw your signature with your finger or mouse.

Your answers save automatically on this device — you can safely leave and come back.

Your privacy matters: information submitted through this form is used only to provide your dental care and is handled in accordance with our Privacy Policy. For anything urgent, call (613) 491-3300.

Consent Forms

Who is this consent for?

Consent to examination & treatment

Privacy & communications

Signature

Thank You — We've Got It!