MOBILE DENTAL HYGIENE SERVICES
Easy as 1, 2, 3!
Print or pick up the Health History Form and Credit Card Authorization Form.
Complete and sign both forms and securely return to Smart Dental Hygiene.
Book an appointment and receive care.
The convenience of having a mobile unit come to the patient’s location saves friends or loved ones from having to take time off work, or time out of their busy schedules to take someone to a clinic. Also, some dental clinics are not equipped to handle patients with special needs or mobility issues, which is a barrier to care.
We can deal directly with family members if patients are unable to make arrangements themselves. Before the initial appointment we must have a health history form and a credit card authorization form fully completed and signed. An appointment will be made only after both forms have been completed and returned to Smart Dental Hygiene. This is to ensure we are able to treat each patient in a safe and effective manner.
If a patient is unable to complete the forms themselves, a parent, guardian, adult child or substitute decision maker may complete and sign the forms for them. Paper forms can be picked up at the clinic or can be mailed to you if requested.
At the initial appointment, a thorough assessment will be done and a written care plan provided outlining our findings and any further recommended treatment. If referrals need to be made, we will indicate this. It is a dental hygiene preventive therapy goal for each patient to be able to speak, smile, and eat without dental pain or discomfort, by preventing infections and maintaining tooth function. If this cannot be achieved by dental hygiene interventions, a referral would be indicated.
In cases where the patient has dental insurance, many insurance companies will let Hygienist Next Door/Smart Dental Hygiene bill directly to them. Many insurance companies allow direct payment to the dental hygienist as they see the increasing benefit and need for their services. If payment cannot be made directly by the insurance company, or if there is a co-payment due, payment may be made by Visa or Mastercard.
Should you have any questions, please do not hesitate to contact us by telephone 519-773-2863 or email anytime.
To download the form, simply click on the links to the right.
Please confidentially submit this form via FAX, MAIL, EMAIL or IN-PERSON to:
Attention: Smart Dental Hygiene
At the Absolute Health & Wellness Centre
587 John Street North
Aylmer, ON N5H 2B6
FAX # 519-773-2934
Have a question?
Forms to be completed.
*BOTH OF THESE FORMS MUST BE COMPLETED, SIGNED, AND RECEIVED PRIOR TO ANY NEW PATIENT MOBILE DENTAL HYGIENE BOOKINGS. APPOINTMENTS WILL NOT BE GIVEN WITHOUT THESE COMPLETED FORMS.