Oral Health Services

If your dental concern is accompanied by swelling and/or fever, we recommend that you seek care from a family physician, walk-in clinic, urgent care center, or emergency room.

For urgent financial assistance for dental care for children 0-17 years old or seniors 65+ years old, contact the Healthy Smiles Ontario program or the Ontario Seniors Dental Care Program by calling 311.

*Indicates required field.

Which age group does the client belong? *

0-17 years old18-64 years old65+ years old

I want to receive information about oral health (education or resources)I want to schedule a dental screening appointment (e.g., Child Care Centre, Neighbourhood/Parenting Group, Public Health Clinic, library programs, Kids and Me, HPNP, or other)I want to apply for financial assistance for dental care

I am receiving Ontario Works and need dental treatmentI am a client of HWP and would like to schedule a dental screening appointmentI am a client of Shifra House and would like a dental screening

CONTENT FOR: I am receiving Ontario Works and need dental treatment

Please call Halton Region by dialing 311.

CONTENT FOR: I am receiving Ontario Works and need dental treatment

YesNo

Which language?

CONTENT FOR: SHIFRA HOUSE LOCATION

Salem HouseSuncrest HousePinedale House

CONTENT FOR: SHIFRA HOUSE LOCATION

NorthSouth

CONTENT FOR: I am a client of HWP and would like to schedule a dental screening appointment

Client name:*

First NameLast Name

Client phone number:*

Phone numberFormat: (000) 000-0000.

Client email:*

Email

YesNo

Name of child

First NameLast Name

Age

CONTENT FOR:

I have an Ontario Senior's Dental Care Program (OSDCP) card and want to set up an appointment with a dentist

Childcare Centre (only children enrolled at a selected centre can be screened)Neighbourhood/Parenting Group, Library Programs, Kids and Me, HPNP, OtherPublic Health Dental Clinic

Your name:*

First NameLast Name

Phone number:*

Phone numberFormat: (000) 000-0000.

Email:*

Email

Organization name, if applicable (optional):

Organization name

Please describe your request:*

Maximum of 3000 characters0/3000

Childcare Centre Name:*

Community Group (Parenting Group, library programs, Kids and Me, HPNP, or other):*

Dental Clinic:*

Teacher's name or classroom:

Name

Child's name:*

First NameLast Name

Add additional children:

Child #2's name (optional):

First NameLast Name

Child #3's name (optional):

First NameLast Name

Child #4's name (optional):

First NameLast Name

Child #5's name (optional):

First NameLast Name

Parent's name:*

First NameLast Name

Phone number:*

Phone numberFormat: (000) 000-0000.

Parent/guardian email:*

Email

Parent's address:*

Street Address

Street Address Line 2

City

Postal Code

Is there anything you want to tell us about your child’s dental need? (optional):

Maximum of 3000 characters0/3000

NeverWithin the past 12 months1 to 2 years ago3 or more years ago

YesNoNot sureExpired Healthy Smiles Ontario card

Your name:*

First NameLast Name

Phone number:*

Phone numberFormat: (000) 000-0000.

Email:*

Email

Organization name, if applicable (optional):

Organization name

Please describe your request:*

Maximum of 3000 characters0/3000

Client name:*

First NameLast Name

Client phone number:*

Phone numberFormat: (000) 000-0000.

Client email:*

Email

Date of appointment*

Date

Time of appointment*

Time of appointment, example 9:00 am

Dentist's name:*

Dentist's first nameDentist's last name

Dentist's phone number:*

Dentist's phone numberFormat: (000) 000-0000.

Dentist's email address:*

Dentist's email address

Describe your current dental concern (optional):

Maximum of 3000 characters0/3000

Client name*

First NameLast Name

Client address*

Street Address

Street Address Line 2

City

Postal Code

Client phone number:*

Phone numberFormat: (000) 000-0000.

Client email:*

Email

Spouse's name (optional):

Describe your current dental concern (optional):

Maximum of 60 characters0/60

In order for you to participate in this program, we would like to collect your personal health information to add you to our waitlist for services. We may also use your information to conduct a survey afterwards for program evaluation. You are not required to provide us with all of your information, but without it, we cannot add you to our waitlist which means you may not be able to receive dental assistance from the program in Halton.

Halton Public Health will follow its internal procedures to help protect your information and will only share the information that is required in order to provide you with care. Although we take steps to ensure your information is secure, due to the risks associated with email communication, confidentiality cannot be guaranteed.

All seniors seeking services from Halton Ontario Seniors Dental Care Program will need to complete an Information, Acknowledgment, and Release and a Code of Conduct for Dental Provider Referral prior to any dental services being offered.

Personal health information is collected on this form pursuant to the Health Protection and Promotion Act and will be used by Halton Region Public Health for navigating clients to dental care and with general program planning and administration. If you have any questions about the collection and use of your information, please visit www.halton.ca/privacy, or call 311 and ask to speak with the Manager of the Oral Health Program.