NEW PATIENT INTAKE FORM

Denture & Implant Cottage

FOR OFFICE USE ONLY

Kim Maximchuk
Rachelle Brochu
Kendall Blanchette

Patient Information

Questions marked with a* are required. Questions you are unsure of or would prefer to answer verbally can be skipped.

Today's Date

Patient Name*

First Last

Date of Birth

Address

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

Home Phone

Cell Phone

Business Phone

Email

Who should we contact in case of emergency?*

First Last

Relationship*

Phone*

Alberta Health Card Number

Do you have dental insurance?*

Yes
No

Primary Insurer

Insurance company name

Certificate / ID number

Group / policy number

Are you a dependant?

Yes
No

Name of insurer

First Last

Date of Birth

Relationship

Secondary insurer

Insurance company name

Certificate / ID number

Group / policy number

Are you a dependant?

Yes
No

Name of insurer

First Last

Date of Birth

Relationship

How did you hear about our clinic?*

Please specify:

Step 1 of 4 - Patient Information

NEW PATIENT INTAKE FORM

Patient Information

Primary Insurer

Secondary insurer

NEW PATIENT INTAKE FORM

Medical history

NEW PATIENT INTAKE FORM

Denture History

NEW PATIENT INTAKE FORM

Consent