Patient Registration Form

Patient Registration Form

By filling this out you are authorizing Beautiful Smiles Denture Clinic to phone & email you. We respect your privacy and do not tolerate spam and will never sell, rent, lease or give away your information (name, address, email, etc.) to any third party.
How did you hear about Beautiful Smiles Denture Clinic? *

Yellow Pages Action Pages Website Coffee News Facebook Bllboard TV Dentist Patient of Beautiful Smiles
Do you have? *

Complete Upper Denture Complete Lower Denture Partial Lower Denture Partial Upper Denture Implants I don't have dentures
If you do have dentures, approximately how old are they and who made them?
If you have dentures, would you like to get them cleaned and polished on your visit? Price $41 per denture (Dental insurance does not cover this) *

Yes No
Would you like information about teeth whitening? *

Yes No
Do you have a dentist? If yes, who is your Dentist?
Do you have a timeline or upcoming event that you need your smile for? *

No Yes
Are you in pain? *

No Yes
Besides getting treatment options, is there anything else you wish to accomplish at your visit?
Personal Information
Title *

Mr. Mrs. Miss. Ms. Dr. Mstr.
Patients Name *

First Name Last Name
Preferred Name
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Birthdate *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Emergency Contact *

First Name Last Name
Emergency Contact Phone Number *

Area Code Phone Number
Insurance Information
Primary Insurance
Insurance Carrier
Policy Plan/Group Number
Subscriber ID Number
Subscriber Name
Relationship to Insured
Subscriber Birthday

Month Day Year
Date
Secondary Insurance

We are only able to direct bill to your primary insurance. However, we are happy to send pre-authorizations and claims to your secondary insurance on your behalf
Insurance Carrier
Policy Plan/Group Number
Policy Plan/Group Number
Subscriber Name
Relationship to Insured
Subscriber Birthday

Month Day Year
Date
Government Funding
First Nations Status Number
Care Card Number if on Disability/Ministry
Medical History
Check all that apply
Chronic Conditions

Alzheimer's Anemia Alcoholism Asthma Arthritis Acid Reflex Cold Sores Dizzy Spells Drug Addiction Diabetes Dementia Dry Mouth Excessive Bleeding Epilepsy Fainting Glaucoma HIV/AIDS HPV Hepatitis (C or B) Hypoglycemia Hyperglycemia High Blood Pressure Low Blood Pressure Latex Allergy Metal Sensitivity Osteoporosis Parkinson's Pacemaker Sjogren's Tuberculosis TMJ Thyroid
Smoke Pipe Vape Chewing Tobacco Artifical Joints/Heart Valves Bruise Easily Head/Neck Injury Do you suffer from hearing loss? Heart Attack Stent
Do you snore and/or are chronically tired? *

No Yes
Have you been diagnosed with sleep apnea? *

No Yes: No CPAP devise Yes: With CPAP devise
Do you grind your teeth? *

Yes No
Do your teeth/dentures stain easily? *

Yes No
Do you suffer from dental anxiety/phobia? *

Yes No
Do use medical devices? (E.g. Walker, wheelchair, oxygen...)
Stroke
Year
Cancer
Type, Year, Treatment
Blood Transfusion
Year
Medications
Allergies
Autoimmune Disease
Mental Illness/ Disorders
Heart Conditions
Other
Cancellation Policy:
Any cancellations within 24 hours or fail to show for an appointment will be charged with a fee of $40. After 3 short notice cancellations/no shows we will not be able to continue our services.
We would love it if you could attached a photo of yourself for your patient file! :) (Optional)

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Check all that apply