New Patient Form | Modern Smiles Denture & Implant Centre

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Alberta Denture Clinic

We understand that trying to find a nearby denturist you can trust is difficult, that is why we make it easy for you to work with us.

(780) 832-0508

admin@modernsmiles.ca

(780) 832-0508

HOME
ABOUT
PATIENT INFORMATION
OUR SERVICES
AT HOME CARE
CONTACT
- Patient Referral

New Patient Form | Dental and Medical Information

Patient Information

Patient Information

First Name

Last Name

Email

Phone Number

Date of Birth

How did you hear about us?

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Emergency Contact

Emergency Contact

Emergency Contact Name

Emergency Phone Number

Emergency Relationship

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Address

Address

Street Address

Unit

City

Province

Postal Code

Country

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Insurance Information

Insurance Information

Do you have dental insurance?

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If yes, please complete the following questions. If no, move onto Medical History

If yes, please complete the following questions. If no, move onto Medical History

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Insurance Company Name

Certificate / ID Number

Policy Number

Policy Holder Full Name

Policy Holder D.O.B.

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Medical History

Medical History

Family physician name

Family physician number

Date of last doctor visit

Dentist name

Dentist number

Date of last dental visit

Have you had dental x-rays taken within the last 2 years?

Do you have any of the following illnesses

Heart disease

High blood pressure

Low blood pressure

Hepatitis A/B/C

Drug addiction

Cold sores

Mouth cancer

Have had radiation or chemotherapy

HIV or AIDS

Other sexually transmitted disease

Epilepsy or seizures

Tuberculosis

Diabetes

Stroke

Jaundice

Asthma

Sinus trouble

Snoring

Thyroid disorder

Arthritis

Digestive disorder

Kidney disease

Gastrointestinal disorder

Bleeding disorder or bruise easily

Respiratory Disease

Rheumatic fever

Do you have any of the following conditions

Facial muscle tenderness

Jaw joint clicking, popping, or locking

Migraines or headaches

Earaches

TMDS (jaw pain)

Neck or shoulder pain

Hearing loss

Lumps or sores in your mouth

Teeth grinding

Sore or tender gums

Snoring

Burning sensation on your lips or tongue

Sleep apnea

Dry mouth

Do you smoke

Cardiac pacemaker

Heart Murmur

Fainting spells

Anxiety

Tumors or growths

Circulatory issues

Anemia

Do you suffer from any illness or condition not listed? (please list)

Are you allergic to latex?

Are you allergic to metals?

Are you allergic to acrylic?

Please list all medications you are currently taking

Please list all major injuries and surgeries in the last 10 years

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Denture History

Denture History

Do you currently use dentures?

Complete Dentures - Upper

Complete Dentures - Lower

Complete Dentures - Upper and Lower

Partial Dentures

Denture Implants

I am new to dentures

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If you are new to dentures, move onto How Can We Help

If you are new to dentures, move onto How Can We Help

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When was your last service?

How old are your dentures?

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How Can We Help

How Can We Help

What are you looking for?

Complete Dentures

Partial Dentures

Denture Implants

Denture Repair

Immediate Dentures

Denture Liner

Custom Sport or Night Guard

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Opt-In

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.

Thank you for completing our New Patient Form.

Our office will review your form and reach out to you if we have additional questions. We may try to contact you before your scheduled appointment to confirm some of your answers.

Please note, if this is a denture emergency, it would be best to call our clinic as this will be the fastest way to reach us (780) 832-0508.

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Call us at (780) 832-0508 Call us at (780) 832-0508

We are the local Alberta denturist near you!

Rediscover your confidence and your smile by using dentures that truly make a difference

Request Your Next Denture Appointment

We look forward to seeing you soon!

Please note, we will try our best to accommodate your schedule.

Full Name

Phone Number

Email

When would you like to come?

What time of day is better for you?

Do you have dental insurance?

Please provide more information. How can we help?

Thank you so much for contacting our denture clinic. While we strive to respond to all inquiries right away, we may be away from the desk helping a patient or out of the office. We will do our best to reach back to you shortly.

Please note, if this is a denture emergency, it would be best to call our clinic as this will be the fastest way to reach us (780) 832-0508.

Oops, there was an error sending your message.
Please try again later

Alberta Denture Clinic

We understand that trying to find a nearby denturist you can trust is difficult, that is why we make it easy for you to work with us.

(780) 832-0508

admin@modernsmiles.ca

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Denture Clinic Hours

High Prairie, High Level, and La Crête are by appointment only

Monday: 8:30 am - 4:00 pm
Tuesday: 8:30 am - 4:00 pm
Wednesday: 8:30 am - 4:00 pm
Thursday: 8:30 am - 4:00 pm
Friday: 8:30 am - 12:00 pm
Saturday: Closed
Sunday: Closed

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All Rights Reserved | Modern Smiles Denture & Implant Centre

© 2024

All Rights Reserved | Modern Smiles Denture & Implant Centre

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