This is an application form for the dental support program. This is NOT a confirmation for the dental support program.

This program is for low income racialized women (Black, Indigenous and Women of Colour) and their accompanied minors. Please make sure to read the description page before applying for this program.

Policy:

This free dental hygiene program provides dental hygiene check-ups and cleaning only. The hygiene clinic can refer you to dentist offices, as needed. You and your accompanied minors need to visit the clinic location. We will not be able to change the location of the clinic for this program. 

Late Show: 

You will not be able to receive the service when you are 20 minutes late for your appointment. Please call the dental hygiene clinic before your appointment time if you are arriving at the clinic more than 5 minutes late. Your appointment will be canceled if you are more than 20 minutes late. 

*Please note: this late show policy applies in any case: no exceptions. 

No Show: 

If you did not show up to the clinic 5 minutes after your appointment without a call to the clinic, you are considered as no-show. If you are considered a no-show client, you will not be able to apply or reschedule for this dental program for the next three months.

*Please note: this no-show policy applies in any case. 

Cancellation & Reschedule: 

If you have to cancel your appointment, you need to email SNIWWOC as soon as possible. If you cancel the appointment and if you wish to reschedule the appointment, you may need to be on the waiting list. 

*Please note: this late show policy applies in any case: no exceptions.

Date

SNIWWOC free dental hygiene clinic opens once a month on Sunday. There are limited spots for appointments. We do NOT accept walk-in clients. 

COVID-19 Safety: 

You must comply with COVID-19 safety plans that SNIWWOC and Pacifica Dental placed.

Consent: 

SNIWWOC is not responsible for any damages disclaimer. You will need to sign the consent with Pacifica Dental on the site.