INTAKE FORM

Patient Information

Patient Name*

First Last

Date of birth

Address

Street Address City Province Postal Code

Phone*

Email*

Occupation

Employer

Emergency contact name

Emergency contact phone*

Are you under the care or treatment of a doctor?

Physician Name

Phone Number

How did you hear about us?

Insurance Company

Insurance Company Address

Street Address City Province Postal Code

Social Security Number

Group / Policy Number

What is the age of your denture?

Where did you receive your last denture?

List the medications you are taking:

Are you dissatisfied with the appearance of your teeth?

Do you have difficulty chewing your food?

Have you had sores on the lips or mouth that are slow to heal?

Do you have dlfficulty opening your mouth wide?

Do you use dental adhesives?

Do you have difficulty with gagging when impressions are taken?

Do you have any problems in the following areas past or present?

Patient signature*

Comments

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