First Name
Last Name
Email
Phone Number
Date of Birth
How Did You Hear About Us? Drive or Walk ByGoogle Search or BingInsurance DirectoryNews or PublicationReferral From Existing PatientSocial MediaOther
Emergency Contact Name
Emergency Phone Number
Emergency Relationship SpouseChildOther Family MemberFriendOther
Street Address
Unit
City
Province
Postal Code
Country
Do you have dental insurance? YesNoUnsure
If yes, please complete the following questions. If no, move onto Medical History
Insurance Company Name
Certificate / ID Number
Policy Number
Policy Holder Full Name
Policy Holder D.O.B.
Family Physician Name
Family Physician Number
Date of Last Doctor Visit
Heart diseaseHigh blood pressureLow blood pressureHepatitis A/B/CDrug addictionCold soresMouth cancerHad radiation or chemotherapyHIV or AIDSOther sexually transmitted disease
Epilepsy or seizuresTuberculosisDiabetesStrokeJaundiceAsthmaSinus troubleSnoringThyroid disorderArthritis
Facial muscle tendernessJaw joint clicking, popping, or lockingMigraines or headachesEarachesTMDS (jaw pain)Neck or shoulder painHearing lossLumps or sores in your mouthTeeth grindingSore or tender gums
SnoringBurning sensation on your lips or tongueSleep apneaDry mouthDo you smokeCardiac pacemakerHeart MurmurAnxietyTumors or growthsAnemia
Do you suffer from any illness or condition not listed? (please list)
Are you allergic to latex? YesNoUnsure
Are you allergic to metals? YesNoUnsure
Are you allergic to acrylic? YesNoUnsure
Please list all medications you are currently taking
Please list all major injuries and surgeries in the last 10 years
Do you currently use dentures?
Complete Dentures - UpperComplete Dentures - LowerComplete Dentures - Upper and Lower
Partial DenturesDenture ImplantsI am new to dentures
If you are new to dentures, move onto How Can We Help
When was your last service?
Less than a year ago1-2-years ago2-3-years old3+ years ago
How old are your dentures?
What are you looking for?
Complete DenturesPartial DenturesDenture ImplantsDenture Repair
Immediate DenturesDenture LinerCustom Sport or Night Guard
I hereby certify that all of the information in this form is true to the best of my knowledge and that I have not knowingly omitted any information. By checking, I agree to share my form responses.
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