New Patient Form | Complete Your Denture and Medial History Form

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Vegreville & Smoky Lake Denture Clinics

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) 632-2722 - Vegreville

(780) 656-3777 - Smoky Lake

(780) 632-2722 - Vegreville

(780) 656-3777 - Smoky Lake

HOME
ABOUT
PATIENT INFORMATION
- New Patient Form
TYPES OF DENTURES
AT HOME CARE
CONTACT VEGREVILLE
- CONTACT SMOKY LAKE

New Patient Form

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

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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

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

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

Dental 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

Dental Implants

Denture Repair

Immediate Dentures

Denture Liner

Custom Sport or Night Guard

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Which clinic are you looking for?

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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) 632-2722.

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Vegreville (780) 632-2722 Smoky Lake (780) 656-3777

We are the local denturist near you!

Putting that sparkle back in your smile

Book Your Next Denture Appointment

We look forward to seeing you soon!

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

Vegreville Denture Clinic

(780) 632-2722

5117 50 Street

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Smoky Lake Denture Clinic

(780) 656-3777

72 Wheatland Ave

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All Rights Reserved | Vegreville Denture Clinic and Smoky Lake Denture Clinic

© 2024

All Rights Reserved | Vegreville Denture Clinic and Smoky Lake Denture Clinic

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