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Trusted denture care in Prince George since 2011
Call today: (250) 562-2620
info@nldenture.ca
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Patient Information
New Patient Form For
Northern Lights Denture
01
Patient Information
Name
Last Name
Email
Phone Number
Date of Birth
How Did You Hear About Us?
Select an option
Drive or Walk By
Google Search or Bing
Insurance Directory
News or Publication
Referral From Existing Patient
Social Media
Other
02
Emergency Contact
Emergency Contact Name
Emergency Phone Number
Emergency Relationship
Select an option
Spouse
Child
Other Family Member
Friend
Other
03
Address
Street Address
Unit
City
Province
Postal Code
Country
04
Insurance Information
Do you have dental insurance?
Select an option
Yes
No
Unsure
If yes, please complete the following questions. If no, move onto Medical History
Insurance Company Name
Certificate / ID Number
Policy Number
Policy Holder Full Name
Policy Holder D.O.B.
05
Medical History
Family Physician Name
Family Physician Number
Date of Last Doctor Visit
Do you have any of the following illnesses?
Heart disease
High blood pressure
Low blood pressure
Hepatitis A/B/C
Drug addiction
Cold sores
Mouth cancer
Had radiation or chemotherapy
HIV or AIDS
Other sexually transmitted disease
Epilepsy or seizures
Tuberculosis
Diabetes
Stroke
Jaundice
Asthma
Sinus trouble
Snoring
Thyroid disorder
Arthritis
Do you have any of the following conditions?
Facial muscle tenderness
Jaw joint clicking, popping, or locking
Migraines or headaches
Earaches
TMDS (jaw pain)
Neck or shoulder pain
Hearing loss
Lumps or sores in your mouth
Teeth grinding
Sore or tender gums
Snoring
Burning sensation on your lips or tongue
Sleep apnea
Dry mouth
Do you smoke
Cardiac pacemaker
Heart Murmur
Anxiety
Tumors or growths
Anemia
Do you suffer from any illness or condition not listed? (please list)
Are you allergic to latex?
Select an option
Yes
No
Unsure
Are you allergic to metals?
Select an option
Yes
No
Unsure
Are you allergic to acrylic?
Select an option
Yes
No
Unsure
Please list all medications you are currently taking
Please list all major injuries and surgeries in the last 10 years
06
Do you currently use dentures?
Complete Dentures - Upper
Complete Dentures - Lower
Complete Dentures - Upper and Lower
Partial Dentures
Denture Implants
I am new to dentures
If you are new to dentures, move onto How Can We Help
When was your last service?
Select an option
Less than a year ago
1-2-years ago
2-3-years old
3+ years ago
How old are your dentures?
Select an option
Less than a year ago
1-2-years ago
2-3-years old
3+ years ago
07
How Can We Help
What are you looking for?
Complete Dentures
Partial Dentures
Denture Implants
Denture Repair
Immediate Dentures
Denture Liner
Custom Sport or Night Guard
I hereby certify that all of the information in this form is true to the best of my knowledge and that I have not knowingly omitted any information. By checking, I agree to share my form responses.
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