Live Patient Course Volunteer Application – Institute of Digital Dentistry

First up, what's your name?(Required)

First Last

What's your email address?(Required)

What’s your mobile phone number?(Required)

Let's get your Date of Birth(Required)

Next let's get your address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

This field is hidden when viewing the form

Now let's get a Smile Photo

Please upload a clear photo of your smile with your teeth visible and an open mouth photo showing the missing teeth area if possible. This helps us to assess your eligibility for the training program.

Drop files here or

Max. file size: 32 MB, Max. files: 1.

Now let's get a Smile Photo(Required)

Accepted file types: jpg, heic, png, pdf, jpeg, Max. file size: 100 MB.

Finally tell us about your reason for volunteering(Required)

Tell us why you would like to be a patient in our course and any other dental information and health background that you think would be relevant.

Please read the Terms and Conditions of Application - A PDF of these terms will be available to download on the next page.(Required)

By submitting this application form, I acknowledge and agree to the following:

TREATMENT UNDERSTANDING
I understand that if I qualify for the program, the following will be provided free of charge:
- Initial dental records including examination, scans, and x-rays (valued at $250)
- Implant surgery during the training program (valued at $3000 per implant)
- Associated bone/gum grafting if required
- Necessary extractions related to implant placement
- Follow-up care for the first 3 months including:
- One-week post-surgery check-up
- One-month follow-up appointment
- Three-month implant integration check
- Any reviews needed within this period if concerns arise

I acknowledge that I will be responsible for paying:
- Crown restoration fee of $3000 per implant, which must be paid upfront to secure my position in the program
- Normal fees for any preliminary dental work required before implant surgery
- Normal fees for any additional treatment not directly related to the implant surgery
- After the initial 3-month healing period, any additional maintenance or follow-up care will incur normal fees
- A 20% cancellation fee of the crown restoration fee if I withdraw or cancel my participation in the program

PROGRAM PARTICIPATION
I understand that treatment will be provided by qualified, registered dentists under specialist supervision as part of a training program at Naenae Dental Clinic on March 14th and 15th 2025

I acknowledge that:
- Not all applicants will be selected for the program
- If selected, I must be available for treatment on the specified dates
- I must attend all required appointments, including follow-up care
- Treatment plans may need to be modified based on clinical findings

CANCELLATION POLICY
I understand and agree that:
- If I withdraw or cancel my participation in the program for any reason, a 20% cancellation fee will be deducted from my crown restoration payment
- This cancellation fee applies regardless of the timing of my withdrawal or cancellation
- The remaining 80% of my crown restoration payment will be refunded using the same payment method
- The cancellation fee helps cover administrative costs, materials ordered, and scheduling impacts

COMMUNICATION CONSENT
I understand that:
- If selected, a team member will contact me to arrange appointments
- I can opt out of promotional communications at any time
- Clinical information may be shared between treating professionals

PRIVACY AND DOCUMENTATION
I agree that:
- My dental records may be used for educational purposes
- Photos and scans may be taken for treatment planning and documentation
- My privacy will be protected in accordance with relevant laws
- De-identified treatment information may be used for educational purposes

TREATMENT SUCCESS
I understand that:
- Dental implant success rates are high but not guaranteed
- My compliance with post-operative instructions is essential
- Following recommended maintenance protocols is crucial

FINANCIAL UNDERSTANDING
I acknowledge that:
- While initial records and implant surgery are free, crown restorations must be paid for upfront
- All costs for additional treatments will be clearly explained before proceeding
- Payment for any additional treatments will be required as per clinic policy
- Financial arrangements must be confirmed before treatment begins

ACKNOWLEDGMENT
- I confirm that all information provided in my application is true and correct
- I understand that providing false information may disqualify me from the program
- I acknowledge that submission of this form does not guarantee acceptance
- I agree to attend all required appointments if selected

I have read and accept these terms and conditions, understand which services are free and which will incur normal fees, and consent to receiving communications from the Institute of Digital Dentistry and Naenae Dental Clinic