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Patient Application Form

 
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Please read this before you start your application:

  • The Clinic is open to everyone 18 years of age and older except for Orthodontic services, which are available to youth and adults up to 35 years old. 
  • All prospective patients must first watch this . The video is a an overview of the Undergraduate Teaching Clinic, the services available, who is eligible to become a patient, the screening process, and our location and contact information.
  • All prospective patients will attend a screening appointment prior to being accepted as new patients*. We are a teaching institution where patients are selected based on the requirements of our educational program. Patients with limited treatment needs (i.e. less than 4 fillings, no need for crowns, root canal treatment, dentures, etc.) are not likely to be accepted for treatment in our clinic.
  • We treat emergency cases on a priority bases. Limited space is available. Please refer to the Emergency services page.
  • Due to the high volume of requests, patient registration is subject to black-out periods. The waiting time for a screening appointment can vary.
  • The clinic is open from September to the end of May.
  • Patients must be able to attend appointments at least once every 2 weeks for 3-4 hours at a time.
  • Recipients of a Quebec government financial assistance program with a claim slip (carnet de réclamation) are not eligible for services in the Undergraduate Teaching Clinic.
  • We accept patients covered under the Canadian Dental Care Plan.
  • Fees are based on the recommendations of the Association des chirurgiens dentistes du Québec.

* Patients requiring root canal treatment that has been diagnosed by a dentist are accepted on a priority basis and may not need to undergo this examination.

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png bmp eps tif pict psd txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml avi mov mp3 ogg wav bz2 dmg gz jar rar sit tar zip.
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