Patient Registration Form Fill in the information Please enable JavaScript in your browser to complete this form.Title: *Patient Name: *Preferred name: Occupation:Street address: *City: *province:postal code: Cellphone: *Home phone: Date of Birth: *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email address: Preferred method of contact: Emergency contact: Insurance information Primary insurance: Policy Plan/Group:Subscriber ID: Subscriber Name: Subscriber Birthday: Employer:Relation to Insured: Care Card Number If on Disability: First Nation’s Status Number: Dental clinic Name: Last visit to a dentist:last X-ray: Do you grind your teeth?YesNoAre you gums tender or sore? YesNoDo you smoke?YesNoDo you have implant?YesNoDo your jaw joint crack, pop or grate?YesNoDo your teeth or denture stain easy?YesNoDo you have old denture? YesNoTMG( Jaw pain)?YesNoFamily PhysicianAre you currently under medical treatment? Medication list Have you ever been treated for or have any of the following? (Put √)Diabetic YesNervous disorder YesHigh blood pressure YesDry mouthYesAutoimmune diseaseYeslow blood pressure YesHeart conditionYesStroke YesAllergies YesThyroid YesEpilepsy or seizures YesRepeat headaches YesHepatitisYesBruise easily YesDrug addictionYesRespiratory disease/ AsthmaYesHIV/AIDS YesCancer YesEmotional YesAlcoholismYesAny allergy YesArthritis YesHearing loosYesSexual transmitted disease YesDo you suffer or want to mention any health concern that is not listed above?Reason of Visit Today:How did you hear about us? By filling out this form, you are authorizing the denture clinic to contact you by phone or email. I hereby certify that all of the information in this form is true to the best of my knowledge and I have not knowingly omitted any information. Signature:Date: Submit
