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Services
Complete Dentures
Immediate Dentures
Partial Dentures
Denture Relines
Nightguards and Retainers
Denture Cleaning
Denture Repair
Digital Dentures
Digital Dentures
Intraoral 3D Scanning
Implant Dentures
Fixed Dentures
Removable Dentures
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Dental Office Referral Form
New Patient Form
Book A Free Consultation
Book A Free Consultation
New Patient Form
Personal information
Title
(Required)
Mr.
Ms.
Mrs.
Name
(Required)
First
Last
Email
Gender
(Required)
Female
Male
Other
Birthdate
MM slash DD slash YYYY
Address
(Required)
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Preferred phone number
(Required)
Alternate phone number
Spouse's name
Dentist
Physician
How were you referred to us?
Dental insurance
Do you have dental insurance?
(Required)
Yes
No
Primary insurance company
Primary policy holder name
If you are not the primary policy holder, please provide their date of birth
MM slash DD slash YYYY
Primary group or policy number
Primary employee, ID, or certificate number
Do you have a secondary dental insurance policy?
(Required)
Yes
No
Secondary insurance company
Secondary policy holder name
If you are not the secondary policy holder, please provide their date of birth
MM slash DD slash YYYY
Secondary group or policy number
Secondary employee, ID, or certificate number
Denture history
Do you currently have a denture(s)?
(Required)
Yes
No
What type of upper denture do you have?
None
Partial lower denture
Complete lower denture
Implant-supported lower denture
What type of lower denture do you have?
None
Partial lower denture
Complete lower denture
Implant-supported lower denture
Who made your denture(s)?
Dentist
Denturist
Other
Do your gums get sore under your denture(s)?
Yes
No
Do you brush your gums under your denture(s)?
Yes
No
Do you wear your denture(s) to bed at night?
Yes
No
Does your denture(s) fit well?
Yes
No
Are you happy with the appearance of your denture(s)?
Yes
No
What don't you like about the appearance of your denture(s)?
Are there any foods you have trouble eating?
Yes
No
What foods do you have trouble eating?
Do you use denture adhesive?
Yes
No
What changes would you like to see in your new denture(s)
If you have never worn dentures, what do you know about them so far?
Dental history
When was your last visit with a dentist?
(Required)
At that visit, what procedure(s) did you have done?
Have you ever had any complications following a dental procedure?
(Required)
Yes
No
Have you had dental x-rays in the past 2 years?
(Required)
Yes
No
Do you have any dental work in progress at this time?
(Required)
Yes
No
If yes, please describe.
Do you have sensitive teeth?
(Required)
Yes
No
I have no remaining teeth
If yes, please describe.
Do your gums bleed?
(Required)
Yes
No
Do you often have a bad, unpleasant, or strange taste in your mouth?
(Required)
Yes
No
If yes, please describe.
Do you experience pain, clicking, or popping in your jaw joint?
(Required)
Yes
No
Do you experience facial, neck, or head pain?
(Required)
Yes
No
Do you grind or clench your teeth?
(Required)
Yes
No
Do you have dental implants?
(Required)
Yes
No
Have you ever had an accident or trauma to your neck or jaw?
(Required)
Yes
No
If yes, please describe.
Do you currently have any sore spots in your mouth?
(Required)
Yes
No
Do you have any habits that affect your mouth?
(Required)
Yes
No
If yes, please describe.
Medical history
Do you have a family physician that you see regularly?
(Required)
Yes
No
Are you under the care of a physician for a specific health concern?
(Required)
Yes
No
If yes, please describe.
Have you recently lost or gained a significant amount of weight?
(Required)
Yes
No
Do you smoke or use chewing tobacco?
(Required)
Yes
No
Do you have frequent indigestion?
(Required)
Yes
No
Are you pregnant?
(Required)
Yes
No
Do you have any of the following health issues? Please select all that apply.
(Required)
Alcohol or drug dependency
Angina pectoris
Anorexia
Arthritis
Asthma
Bleeding disorder
Bulimia
Cancer
Chemotherapy or radiation
Cholesterol problems
Cold sores
COPD
Depression
Diabetes Type 1
Diabetes Type 2
Difficulty breathing
Dizziness or fainting
Emphysema
Epilepsy or seizures
Fibromyalgia
Heart attack
Heart disease
Heart murmur
Hepatitis A
Hepatitis B
Hepatitis C
Herpes virus
High blood pressure
HIV or AIDS
HPV
Immune deficiency
Kidney disease
Kidney stones
Liver disease
Low blood pressure
Nervousness
Psychological disorder
Rheumatic fever
Sexually transmitted disease
Stroke
Tuberculosis
No health issues
Do you have any of the following allergies? Please select all that apply.
Drug allergies
Environmental allergies
Latex allergy
Other
Please list all current medications.
Have you ever experienced a bad reaction to any of the following medications? Please select all that apply.
Anaesthethic
Barbiturates (sleeping pills)
Codeine
Cortisone
Penicillin
Sulphonamides (sulfa drugs)
Tranquilizers
Other
Have you had any of the following surgeries? Please select all that apply.
Artificial heart valve
Artificial joint replacement
Heart surgery
Organ transplant
Pacemaker
Other
Have you ever had a serious illness that required hospitalization?
(Required)
Yes
No
Do you have any other health issues which have not already been addressed in this questionnaire?
Click here to indicate that you hereby certify the information you are submitting to be complete and accurate.
(Required)
Yes, my information is complete and accurate
I consent to the collection, use, and disclosure of my Personal Information as set out in the Terms of Patient Consent
(Required)
Yes, I consent
I consent to the collection, use, and disclosure of my Personal Information as set out in the Terms of Patient Consent
Yes, I consent
Note to client
Your consent is required. This means that we want you to understand the services we hope to provide to you, the cost involved, and what we do with the personal information we obtain about you. If you have any questions regarding our privacy policy, please ask.
Consent for Personal Information
I understand that to provide me with denture health care goods and services, the denturist will collect some personal information about me such as, but not limited to, home address, telephone number, medical history, and photos.
I understand that in accordance with this denturist’s Privacy Policy, the collection and disclosure of my personal information will be protected and remain within the scope of this denturist’s practice and in relation to the provision of denture health care.
I understand how this policy applies to me, and I have been given a chance to ask.
Any questions I have about the Privacy Policies, and they have been answered to my satisfaction.
I understand that the signature on this form will be kept on my file. I, the undersigned, hereby certify the information given by me to be accurate.
Consent to Submit Claim Electronically
I authorize release, to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I hereby assign my benefits, payable from claims submitted electronically to Monica Johnson, DD, and authorize payment directly to her. This authorization shall continue in effect until the undersigned revokes the same.
