Hamilton Clinical Chart/notes For Denture/partial Pre-Determination(S) Repairs, Additions And Relines
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1
2
3
4Public Health Dental and Denture Program
rd
110 King St. West, 3
Floor
Hamilton, ON
L8P 4S6
Telephone: 905.546.3566
Fax: 905.546.3659
Clinical Chart/Notes for Denture/Partial Pre-determination(s)
Repairs, Additions and Relines
For
Ontario Works Adult, Ontario Disability Support Program and Low Income
Discretionary Denture Program
Please fax or mail to Public Health Dental and Denture Program.
Date:
dd/mm/yy
Last Name
First Name
Middle Name
Mr
Ms
Mrs
Miss
Date of Birth
Day
Month
Year
Health Card #
Address
City
Postal Code
Living in a long-term care/residential facility:
Name of facility:
Yes
No
The patient is a resident of the City of Hamilton: Yes
No
Section A: Pre-determination for: Relines and Repairs
Relines
Upper Denture
Upper Partial
Date of last reline:
dd/mm/yy
Date of last reline:
dd/mm/yy
Lower Denture
Lower Partial
Date of last reline:
dd/mm/yy
Date of last reline:
dd/mm/yy
Repairs
Upper Denture
Upper Partial
Date of last repair:
dd/mm/yy
Date of last repair:
dd/mm/yy
Lower Denture
Lower Partial
Date of last repair:
dd/mm/yy
Date of last repair:
dd/mm/yy
The remaining part of the chart after this section is not to be filled in. Please proceed to
page 3, Section D and E.
Section B: Pre-authorization for full dentures and partials (cast and acrylic):
Fill in the remaining chart, date and sign
Upper Full Denture
Lower Full Denture
Upper Cast Partial
Lower Cast Partial
Upper Acrylic Partial
Lower Acrylic Partial
dd/mm/yy
Signature:
Date:
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