STANDARD DENTAL TREATMENT FORM
APPROVED BY THE CANADIAN DENTAL ASSOCIATION
DATE PREPARED THIS ESTIMATE IS VALID UNTIL
UNIQUE NO. SPEC. PATIENT’S OFFICE ACCOUNT NO. DAY MO YEAR DAY MO YEAR
P D
A LAST NAME _______________________ GIVEN NAME ____________ E
T N
I T
E ADDRESS_____________________________________APT.________ I
N S
T CITY____________________ PROV. ______ POSTAL CODE _______ T Tel. No. __________________________________________________
OFFICE VERIFICATION
Examination: (Fees Only) ____________________________________ $ ________________ ADDITIONAL COMMENTS: Use this space to provide other information pertinent to
the treatment plan.
Radiographs: (Fees Only) ____________________________________ $ ________________
Other Diagnostic Services: (Total Fee Only) ______________________ $ ________________ +L
Oral Hygiene Instructions: (Fees Only) __________________________ $ ________________
Other Preventive Services: ___________________________________ $ ________________
Prophylaxis/Fluoride: (Fee Only) ______________________________ $ ________________
Basic Restorative Services:
(Do not itemize surfaces, fees or teeth here. Total Fee Only) ________ $ ________________
Surgery: (Total Fee Only) ____________________________________ $ ________________ +L
Periodontal Services: (Total Fee Only) __________________________ $ ________________ +L
Endodontic Services: Tooth _____________________________ $ ________________
(Give Fee per Tooth) Tooth _____________________________ $ ________________
Tooth _____________________________ $ ________________
Tooth _____________________________ $ ________________
Tooth _____________________________ $ ________________
Tooth _____________________________ $ ________________
Anesthetic Services: (Total Fee Only) ___________________________ $ ________________ +Drugs
Orthodontic Services: (Total Fee Only) __________________________ $ ________________ +L
Other Services, including Crowns, Bridges and Dentures (Itemize tooth,
service and professional fee, but not commercial lab charge.)
_________________________________________________________ $ ________________ +L
_________________________________________________________ $ ________________ +L
THIS SECTION TO BE COMPLETED BY PATIENT
_________________________________________________________ $ ________________ +L
_________________________________________________________ $ ________________ +L
NAME ________________________________________________________________________
_________________________________________________________ $ ________________ +L
ADDRESS _____________________________________________________________________
_________________________________________________________ $ ________________ +L
_________________________________________________________ $ ________________ +L S _____________________________________________________________________________
U
_________________________________________________________ $ ________________ +L
B
EMPLOYER ____________________________________________________________________
_________________________________________________________ $ ________________ +L S
C
_________________________________________________________ $ ________________ +L R ADDRESS _____________________________________________________________________
I
B
Total Estimated E GROUP POLICY CERTIFICATE NO. SOCIAL INSURANCE NO.
Lab Charges $ __________________________ R
TOTAL ESTIMATE $ __________________________ DAY MO YEAR RELATIONSHIP TO SUBSCRIBER
PATIENT’S DATE
OF BIRTH
SERVICES MARKED (L) ARE APPROXIMATIONS ONLY.
L FINAL LABORATORY CHARGES WILL BE INCLUDED ON CLAIM FORM.
I authorize the release of the information outlined in this
treatment form to my insurance company or its agents.
H SERVICES MARKED (H) WILL BE PERFORMED IN HOSPITAL.
I also authorize the release of information related to the
coverage of services (as described on this form) to the
__________________________________________
SIGNATURE OF PATIENT (OR GUARDIAN/PARENT)
named dentist.
