Responsible Dentist and Practice Arrangements Form

This form must be completed by the Responsible Dentist. The purposes of this form are to identify a Responsible Dentist, the structure of the Practice and those that are involved in the operations and management of a Practice. Refer to the Standard of Practice: Practice Arrangements and Provision of Professional Services for guidance.

A. Trade Name of Practice

A. Trade Name of Practice(Required)

B. Practice Information

Please fill in the information about the practice

Practice Address(Required)

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

Practice Phone(Required)

Practice Fax

Practice Email(Required)

Practice Website

Names of all dentists working at the practice(Required)

First Name

Last Name

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C. Practice Owner Information

Owner Name(Required)

Prefix First Last

Practice Permit Registration Number(Required)

Owner Email Address(Required)

The Owner's Contact Address is:(Required)

The same as practice address

A different address (specify)

Owner Contact Address(Required)

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

Owner Phone(Required)

D. Responsible Dentist

Every Practice must appoint a Responsible Dentist. The owner of the Practice may be but is not required to be the Responsible Dentist. The Responsible Dentist must have continuous and ongoing connection to the Practice including involvement in and knowledge of the operations.

Responsible Dentist is the same as the owner?(Required)

Yes

No

Name of Responsible Dentist(Required)

Prefix First Last

Practice Permit Registration Number(Required)

Responsible Dentist Email(Required)

Responsible Dentist contact information is the same as practice Information?(Required)

Yes

No

Contact Address of the Responsible Dentist(Required)

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

Responsible Dentist Phone(Required)

E. Practice Structure Information

Details about the Practice:

Partnership of Dentists

Partnership of dentists and/or their professional corporations but not a Limited Liability Partnership which is prohibited.

Name of Partner/Partnerships

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Practice in Association

Practice in Association: A regulated member or professional corporation in a cost sharing arrangement for a Practice. Certain costs are shared of the Practice, such as joint advertising, shared office telephone number, office reception area, office or clinical expenses and shared employees as set out in section 97(1) of the Health Professions Act.

Name of each regulated member or professional corporation in the arrangement

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Professional Corporation

Professional corporation: A single professional corporation that may have agreements with associate dentists and those associates may or may not have their own professional corporations.

Name of associate dentist(s) and/or professional corporation(s) if any

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Sole Dentist Owner

Sole dentist owner: A Practice with a single dentist owner who does not have a professional corporation and is a sole proprietor. A sole dentist owner may have agreements with associate dentists and those associates may or may not have their own professional corporations

Name of associate dentist(s) and/or professional corporation(s) if any

Other

Please Describe(Required)

F. Management Services:

Management Services are provided by a:(Required)

Individual

Entity

Name(Required)

First Last

Email(Required)

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Name of Entity providing management services

Entity Name

Contact Name

Contact Email

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Entity Name(Required)

Contact Name(Required)

Email(Required)

Declaration

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Date Submitted