Intake form 2023 - Signature 28 Denture Clinic

PATIENT INFORMATION

Today's Date(Required)

MM slash DD slash YYYY

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Address(Required)

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

Home Phone Number

Cellphone Number(Required)

EMERGENCY CONTACT INFORMATION

Name of your Emergency Contact(Required)

First Last

Phone Number of Emergency Contact

INSURANCE INFORMATION

ALBERTA HEATH CARE NUMBER (Seniors over 65 years old only)

NAME OF INSURANCE COMPANY

POLICY/ PLAN/ GROUP #

IDENTIFICATION NUMBER (ID #)

DIV #

Are you the Primary Subscriber of this Insurance Policy

Yes

If you answered "No" to the above, please provide the name of the Primary Subscriber

First Last

Date of Birth of Primary Subscriber

MM slash DD slash YYYY

MEDICAL/ DENTAL HISTORY

Aside from the regular routine exams, are you currently being followed by a physician or specialist?(Required)

Yes

If you answered "Yes", what are your being followed for?

In the last two (2) years, have you had a serious illness or been hospitalized?(Required)

Yes

If you answered "Yes", please provide us some additional details on the cause of hospitalization or illness.

Do you have any Allergies?(Required)

Yes

What allergies do you suffer from? (Latex, Nuts, Medications, Specific Foods, etc.)

Alcohol Issues

Drug Dependency

Hepatitis A

Hepatitis B

Hepatitis C

Other Liver Disease

Arthritis

Artificial Joint Replacement

Diabetes

Eating Disorder

Epilepsy/ Seizure Disorder

HIV/ AIDS

Immune Deficiency

Cold Sores

High Cholesterol

High Blood Pressure/ Low Blood Pressure

Bleeding disorder/ Hemophilia

Nervousness/ Psychiatric Condition

Organ transplant

Tuberculosis

Asthma

Difficulty Breathing

Emphysema

Chronic Obstructive Pulmonary Disease

Cancer

Chemotherapy

Radiation Therapy

Dizziness/ Fainting

Kidney stones

Kidney disease

Heart Attack/ Heart Disease

Heart Murmur

Heart Surgery

Artificial Heart Valve

Pacemaker

Angina Pectoris

Rheumatic Fever

Surgery

NONE OF THESE APPLY TO ME

Are there any other health issues, not listed above, that you wish to tell us about? If so, please provide additional details.

Are you currently taking any medications, prescriptions, or herbal remedies?(Required)

Yes

If you answered 'Yes", please provide the names of your medications/ herbal supplements

Have you recently gained or lost weight?(Required)

Yes

Do you frequently have indigestion?(Required)

Yes

WOMEN: Are you currently pregnant?(Required)

Yes

Not Applicable

DENTURE INFORMATION

How long have you had your CURRENT dentures?

Are you currently pleased with the appearance of your dentures? If no, please explain.

Are you pleased with the fit, comfort, and functional state of your dentures? If no, please explain.

Do you currently have dental implants?

Yes

No, but I would like to discuss the possibility of dental implants

FINANCIAL

Please note that a 50% deposit is collected on the day treatment is initiated. The remaining balance is due upon delivery of your denture(s). Delinquent accounts are subject to interest charges of 2% per month (26.8% per annum) and third party collection fees. Thank you for your understanding.

(Required)

I have read and understand the financial policies of Signature 28 Denture Clinic

CONSENT

How did you hear about Signature 28 Denture Clinic?

Google Search

Radio Advertisement

Promotional flyer

Friend/ Family Referral

OTHER

If this is a friend/ family referral, please share their name so we can personally thank them.

Signature

Consent(Required)

I confirm the information I have provided is truthful and accurate. I willingly consent to receive dental treatment at Signature 28 Denture Clinic.

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SIGNATURE 28 DENTURE CLINIC

PATIENT INFORMATION

EMERGENCY CONTACT INFORMATION

INSURANCE INFORMATION

MEDICAL/ DENTAL HISTORY

DENTURE INFORMATION

FINANCIAL

CONSENT

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