Denture Acceptance Form

1)Try-in appointment, 2) Insert Appointment

During the try-in and insertion appointments, the student will show you your denture set up. Through the try-in and
insertion appointments, you will need to address with the student any concerns you may have regarding our denture.

In order to ensure success, regarding your treatment goals and the learning experiences for our students, we will ask
you to approve the final steps in the denture process. Once the insertion appointment has been completed no further
changes to your denture other than minor adjustments can occur.

NOTE: You will be given a copy of this form for your records and a copy will be scanned and placed in your client record.

Try- in Appointment

Student Responsibilities:

 Explains process of try in appointment to client

 Addresses client’s questions regarding Denture
 Discusses next steps of denture process -processing.
 Confirms client’s acceptance of set-up (tooth size/shape/colour, fit, function etc.)
 Mentions to client final payment is required at next appointment for client to take denture home

Client Responsibilities:

 Client confirms try-in denture is acceptable. CLIENT INITIALS HERE ________________

Insert Appointment

Student Responsibilities:

 Explains process of insert appointment to client

 Addresses client’s questions regarding processed denture
 Makes required adjustments
 Makes post insert appointment
 States to client final payment is required to take denture home

Client Responsibilities:

 Accepted processed denture CLIENT INITIALS HERE ________________

Printed Name of Client or Legal Guardian: _________________________________________

Signature of Client or Legal Guardian: ___________________________ Date: ____________________

Student Initials: _________________________ Faculty Initials: _____________________________

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