Intake formInterested in working together? Fill out some info and we will be in touch shortly! We can't wait to hear from you! Name * First Name Last Name Email * Phone Number * (###) ### #### Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Personal Health Number Emergency Contact Name First Name Last Name Emergency Contact Phone Number (###) ### #### Primary Dentist First Name Last Name Dentist Phone Number (###) ### #### Date of last dental appointment? MM DD YYYY Do you have any of the following? Alzheimer's Disease Cold Sores Sexually Transmitted Disease High or Low Blood Pressure Cancer Radiation / Chemotherapy Migraines Diabetes Head / Neck Injury Dry Mouth Stroke Use of Recreational Drugs Arthritis Oral Thrush Heart Disease / Artificial Valves or Stents Mental Disorder Epilepsy or Seizures Hypoglycemia or Hyperglycemia Thyroid Disorder Parkinson's Disease TMJ Disorder / Jaw Pain Nervous Disorder Facial Muscle Pain Tuberculosis (TB) Is there any other information we should know that is not listed? Are you taking any medication, non-prescription drugs or herbal supplements? Please list below: Do you have any of the following allergies? Rubber Metals Plastic Other allergies that we should know about? Has your weight, appetite or energy level changed dramatically recently? Yes No I Don't Know Do you smoke or use tobacco? Yes No Line Current Age of Dentures How long have you been wearing dentures? Chief complaint Please let us know a brief summary of why you are booking with us: Current Issues with your dentures, if applicable: Fit Appearance Stains Chewing Comfort Speech Plaque Build-Up Jaw Pain Other If other, please explain: Do you wear dentures at night? Yes No Are your dentures loose? Upper Lower Both No Do you have a strong gag reflex? Yes No Do you grind your teeth? Yes No Please indicate the type of changes that you would like to see with your new dentures (If applicable): Tooth Size Tooth Color Tooth Shape Lip Support Bite Position Better Fit Any other changes that you would like? Do you give your consent for Arbutus Denturist Inc. to use any pictures and/or videos taken for educational, instructional, or promotional purposes? * Yes No Do you give your consent to Arbutus Denturist Inc. to speak with your Dentist, Doctor, family member or POA about your treatment if required? * Yes, I consent To the best of my abilities, the above information is correct. * Yes Thank you so much for submitting your intake form online.We will receive this information shortly.If required, we may need to confirm this information in person with a signature.
