Pre-Appointment Form

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Pre-Appointment Form

Patient Information and Consent Form

Download this Form.
Date*
Full Name of Patient*
First Last
Name & Phone Number of Parent/Guardian/Caregiver/POA:*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Date of Birth*
Age*
Gender*
- Male
- Female
Home Phone*
Work Phone*
Cell Phone*
Referred By:*
Employer:*
Do you have any benefits/coverage:*
- Yes
- No
SHC Number:*
Insurance Company:*
Group Number:*
Client ID Number:*
Do you still have natural teeth:*
- Yes
- No
Do you currently wear dentures:*
- Yes
- No
If YES, what kind of dentures do you wear:*
Age of present dentures:
Complete Upper/Complete Lower/Acrylic Partial/Metal Partial Dentures made by:*
Last dental procedure:*
Date of last dental procedure*
Personal Dentist:*
Personal Physician:*
What is the reason for your visit today?*
Medical Information (please provide ALL necessary details in blank space provided):
Are you in generally in good health at the present time?*
- Yes
- No
Are you under the care of a physician at the present time?*
- Yes
- No
Are you taking any medications at the present time?*
- Yes
- No
Are you allergic to any medications?*
- Yes
- No
Is there any history of family disease?*
- Yes
- No
Have you ever had a heart attack?*
- Yes
- No
Have you ever had a stroke?*
- Yes
- No
Have you ever undergone Chemotherapy/Radiation Treatment?*
- Yes
- No
Are you currently undergoing Chemotherapy/Radiation Treatment?*
- Yes
- No
Do you wear any type of prosthetic device? (i.e. hearing aids, prosthetic joints, pace-maker etc.)*
- Yes
- No
Are you currently on any ANTIBIOTICS?*
- Yes
- No
Have you had serious injury, surgery, or x-ray therapy to your head and neck?*
- Yes
- No
Do you clench or grind your teeth?*
- Yes
- No
Do you currently, or have you ever suffered from any of the following conditions? (please check all that apply)
- AIDS/HIV
- Allergies
- Anemia
- Arthritis
- Bleeding Disorders
- Cancer
- Chronic Headaches
- Sleep Apnea
- Snoring
- Breathing Disorders
- Heart Disease
- Diabetes: Type1/Type2
- Dry Mouth
- Hepatitis
- Epilepsy
- Gastrointestinal Disorders
- High Blood Pressure
- Low Blood Pressure
- Thyroid Disorders
- TMJ (Jaw) Problems
- Mental/Nervous Disorders
- Menopause
- Tuberculosis
- Sinusitis
- Sexually Transmitted Diseases
- Kidney Disorders
- Chronic Neck/Back Pain
- Chronic Bad Breath
- Bleeding Gums
- Periodontal Problems
Other
Medications
I have read and understand all of the above questions, and have made every effort to answer them truthfully. I give full consent to my denturist to collect all other necessary medical and dental information from my doctor, dentist, and/or oral surgeon, relevant to such treatment as may be required.
Signature of Patient/Guardian/POA:*
Date

phone 306-682-4357

fax 306-682-3620

Open Hours

Mon-Thurs 9am – 4pm
Fri 9am-3pm

(Extended hours by appointment only)

Pre-Appointment Form

Patient Information and Consent Form

Open Hours

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