Returning Patient Medical History

Patient Name*

First Last

Date of birth*

Home Phone

Cell Phone

Family Doctor*

Dentist*

Do you have dental insurance?*

Yes
No

Has your dental insurance changed?*

Yes
No

Do you have or have had any of the following:

Are you taking any prescription/non-prescription medications?*

Yes
No

Please list or bring a copy to your appointment.

Have you had significant weight loss?*

Yes
No

Do you get food under your dentures?*

Yes
No

My Upper denture is loose

Yes
No

My Lower denture is loose

Yes
No

Do you use store bought adhesives?*

Yes
No

Do you chew well with your dentures?*

Yes
No

Do you have gum pain or ulcers?*

Yes
No

Do you experience dry mouth?*

Yes
No

Do you chew mints or gum?*

Yes
No

Do you bleed or bruise easily?*

Yes
No

Do you grind or clench your teeth?*

Yes
No

Do you smoke?*

Yes
No

Do you have hearing issues?*

Yes
No

Do you have memory issues?*

Yes
No

Do you have allergies to any of the following:*

Select All
Latex Gloves
Metals
Plastics
None

Do you have any other allergies?

If you have any natural teeth remaining, when was your last visit with a dentist?

What are your concerns with your current dentures?*

Consent

Consent*

I certify that the medical and dental information I provided is accurate to the best of my knowledge.*

Consent*

I consent to have treatment at Brookswood Denture clinic and this consent will apply to each appointment I need to complete treatment.*

Consent*

I understand that I may be seeing my denturist several times to complete denture treatment and it is not possible to maintain social distancing of 2 metres (6 feet).*

Consent*

I assume responsibility for all fees incurred. All fees not covered by my insurance company will be my responsibility.*

Name of person filling out this form

First Last

Phone

Signature

Comments

This field is for validation purposes and should be left unchanged.