Download our Application Form
Interested patients must complete an application form to qualify in this program. The application is intentionally comprehensive to establish the patient’s desire and motivation to improve their dental health. There is a $50 administration fee, to be paid upon delivery of the completed application in order for it to be reviewed and to schedule the consultation appointment. While the application fee is non-refundable, all applicants will receive the benefit of a comprehensive oral examination by a dentist and all necessary radiographs to develop an appropriate treatment plan.
As part of the application process, prospective patients must agree to each of the program policies and rules, and initial each line to verify such.
The application form will request the following information:
- Personal Statement Form
- How has your dental condition negatively affected your life?
- What are you hoping to achieve by restoring your oral health?
- Confidential Financial Information
- Copies of last two years Notice Of Assessment from Canada Revenue Agency (or specific lines disclosed) from the patient and their spouse or common law partner or parent
- Federal Low Income Cut-Offs are used as a guide for qualifying applicants
- Personal Information, Medical and Dental History Questionnaire
- Fundy Dental Centre standard health information form
- Personal Reference Form
- Any adult non-relative can act as a personal reference
- Personal Reference Template Form to be filled out
- Details the ways the applicant’s oral health has negatively affected their life
- A description of the applicant’s need and desire to be provided, and whether or not the personal reference would recommend the patient for treatment in the FDC program
- Program Rules & Policies
- The applicant must agree to all of the program rules and policies by initialing each line
- Treatment Expectations
- Patients are made aware of the scope of treatment provided under this program
Download our Application Form and submit the complete form and $50 fee in person to Fundy Dental Centre for qualification into this program. Any questions can be emailed to firstname.lastname@example.org