Consent form for visiting dental services
What we ask for before a visit, who can sign it, and how to send it back.
A registered dentist will be visiting the home to provide dental assessments and treatment to residents who wish to avail of the service. Dental care may include oral examinations, denture assessments and adjustments, preventive care, emergency or urgent treatment, and other procedures the dentist considers appropriate — all carried out to professional dental standards and in the resident's best interests.
Medical information
We ask for any medical information the dentist should know before attending — in particular current medications, a medical card number where there is one, and any allergies, including drug allergies.
Consent declaration
By signing, you confirm that:
- You are the resident named, or the resident's next of kin or legal representative.
- You understand the nature of the dental services being provided within the home.
- You consent to the dentist carrying out dental examinations and any necessary treatment.
- You understand that not all treatment is covered by a Medical Card and that private fees may apply, which are set out before any private treatment begins.
- You understand that consent may be withdrawn at any time.
How to return it
Email the signed form to hello@dentistry2u.ie, or hand it to our team on the day. Nursing homes arranging a clinic day are sent the form as a batch, with the resident list template, when the date is agreed.
Personal and health information on this form is processed only to plan and deliver dental care, and is handled in line with our privacy policy.
Arranging a clinic day?
Phone the office and ask. We send the resident list template and consent forms the same day.