CDCP Consent FormCDCP Consent FormName of the Patient:* First Last Name of the Guardian: First Last I acknowledge that I am a patient or guardian of a patient at Henley Dental and who has the Canadian Dental Care Plan (CDCP) insurance coverage. I understand and agree that Henley Dental charges in accordance with the current year Ontario Dental Association fee guide prices for the services provided. I further acknowledge that any difference between the fee charged by Henley Dental and the amount covered by CDCP insurance plan is my responsibility for payment.Consent* I hereby consent to the treatment provided by Henley Dental and agree to be responsible for any uncovered fees.Email* Date* Year Month DaySignature Of Patient/Guardian:*CaptchaCommentsThis field is for validation purposes and should be left unchanged.
