Part A. Information for prospective patients

Thank you for your interest in seeking treatment in the Undergraduate Teaching clinic at the Dr. Gerald Niznick College of Dentistry (College). We provide high quality, comprehensive care for about 50% the cost of a private office. All treatment is provided by College learners of dentistry and dental hygiene, under the supervision of a licensed dentist or registered dental hygienist.

  1. Educational Institution: The College is an educational institution. All patient applicants must be deemed suitable for treatment by College learners of dentistry and dental hygiene (i.e., students) for educational purposes.
  2. Consent and Waiver: All accepted patients must sign a Consent and Waiver form. They must also sign informed consent forms as required for certain treatment.
  3. Fees: Patients must pay a non-refundable non-insured registration fee (currently $20.00). Treatment costs are approximately half of private dental clinics – i.e., 50% of the fees set out in the Manitoba Dental Association Fee Guide. The fees quoted by the College are subject to change, as treatment plans and may change from time to time, in the sole discretion of the College.
  4. Payment: The patient must pay all fees on the date treatment is provided. For extensive procedures, one half of the total fee is required at the beginning of the appointment and the remainder payable at the end. Payment by personal cheque or American Express is not accepted.
  5. Personal Information: Patient personal information, including casts, x-rays and photos, are collected by the College for treatment, education and research. Any questions about access and privacy laws may be directed to the University’s Access and Privacy Office, 233 Elizabeth Dafoe Library, Winnipeg, MB R3T 2N2. Telephone: 204-474-8339.
  6. Treatment and Timing: Treatment is provided by College learners of dentistry and dental hygiene, under the supervision of a licensed dentist or registered dental hygienist. The treatment process is slower than in a private practice. It may take several weeks to arrange for your initial appointment if accepted. Each appointment may take up to three hours. It may take over a year to complete the agreed upon treatment plan. Service is limited during the summer months.
  7. Appointment Reminder System: The College uses an electronic appointment reminder system (via email, text or telephone) to confirm appointments. Patients must inform the College of any changes in their contact information. Please be on time for your appointments, or cancel at least one day in advance.
  8. Safe and Secure Environment: Patients must comply with all College requirements intended to ensure a safe and secure environment including all policies regarding needle stick injuries and blood borne pathogens. Failure to comply with the College’s rules and requests to ensure a safe and secure environment will result in the appointment being cancelled and potential dismissal as a College patient. Please ensure that you behave in an appropriate manner at all times.
  9. Medical Emergencies: If a patient requires emergency medical care during an appointment, the College will contact 911 for assistance. Any transportation to hospital will be by ambulance. The patient is responsible for ambulance costs.

 

Part B. Patient application

This is an application for:

 

Personal info of patient

Title

 

Contact information

Please format as the following "204-123-1234"

 

Mailing address

Street address/P.O. Box

 

Emergency contact

Please format as the following "204-123-1234"

 

Coverage

Do you have coverage (e.g., insurance, social assistance, NIHB)?
INSURANCE
SOCIAL ASSISTANCE

 

Terms and conditions



Thank you for your interest in seeking treatment in our program at the Dr. Gerald Niznick College of Dentistry (College). Please read, sign and keep your copies of College documents in a safe place.

  1. Educational Institution:  The College is an educational institution. All patient applicants must be deemed suitable for treatment by College learners of dentistry and dental hygiene (i.e., students) for educational purposes.
  2. Consent and Waiver:  All accepted patients must sign a Consent and Waiver form.  They must also sign informed consent forms as required for certain treatment.  
  3. Fees:  Patients must pay a non-refundable non-insured registration fee (currently $19.00).  Treatment costs are approximately half of private dental clinics – i.e., 50% of the fees set out in the Manitoba Dental Association Fee Guide.  The fees quoted by the College are subject to change, as treatment plans and may change from time to time, in the sole discretion of the College.
  4. Payment:  The patient must pay all fees on the date treatment is provided. For extensive procedures, one half of the total fee is required at the beginning of the appointment and the remainder payable at the end.  Payment by personal cheque or American Express is not accepted.
  5. Personal Information:  Patient personal information, including casts, x-rays and photos, are collected by the College for treatment, education and research.  Any questions about access and privacy laws may be directed to the University’s Access and Privacy Office, 233 Elizabeth Dafoe Library, Winnipeg, MB R3T 2N2.  Telephone:  204-474-8339.  
  6. Treatment and Timing:  Treatment is provided by College learners of dentistry and dental hygiene, under the supervision of a licensed dentist or registered dental hygienist.  The treatment process is slower than in a private practice.  It may take several weeks to arrange for your initial appointment if accepted.  Each appointment may take up to three hours.  It may take over a year to complete the agreed upon treatment plan.  Service is limited during the summer months.
  7. Appointment Reminder System:  The College uses an electronic appointment reminder system (via email, text or telephone) to confirm appointments. Patients must inform the College of any changes in their contact information.  Please be on time for your appointments, or cancel at least one day in advance.
  8. Safe and Secure Environment:  Patients must comply with all College requirements intended to ensure a safe and secure environment including all policies regarding needle stick injuries and blood borne pathogens.  Failure to comply with the College’s rules and requests to ensure a safe and secure environment will result in the appointment being cancelled and potential dismissal as a College patient. Please ensure that you behave in an appropriate manner at all times.  
  9. Medical Emergencies:  If a patient requires emergency medical care during an appointment, the College will contact 911 for assistance.  Any transportation to hospital will be by ambulance. The patient is responsible for ambulance costs.


Notice Regarding Collection, Use, and Disclosure of Personal Health Information by the University

Your personal health information is being collected under the authority of The University of Manitoba Act. The information you provide will be used by the University for the purpose of setting up your patient record with the Dr. Gerald Niznick College of Dentistry and booking your initial screening. Your personal health information may be disclosed to insurance companies for billing purposes. Your personal health information will not be used or disclosed for other purposes, unless permitted by The Personal Health Information Act (PHIA). If you have any questions about the collection of your personal health information, contact the Access & Privacy Office (tel. 204-474-9462), 233 Elizabeth Dafoe Library, University of Manitoba, Winnipeg, MB, R3T 2N2.