Denture Clinic | Dingley Village and Emerald

Surname:

First Name:

Address

Suburb:

State:

Postcode:

Date of Birth:

Phone:

Mobile No:

Health Fund:

Extra's

Yes

No

Email:

Who is your dentist? (name & contact number)

Who is your medical practitioner? (name & contact number)

Do you have any of the following dentures?

Full Upper

Full Lower

Partial Upper

Partial Lower

Are you happy with their appearance?

How long have you worn dentures?

Are your current dentures loose?

How old are your current dentures?

Do suffer from any of the following:

Dry Mouth

Sore spots or leisons

Denture discomfort

Dental caries or plaque

Do you have a hearing impairment?

Do you suffer from allergies? If yes, please list (including latex)

Do you have any of the following?

High Blood Pressure

Diabetes

Heart Complaint

A nervous condition

Cancer/Chemo Treatment

Epilepsy

Contact with a Contagious Disease (hepatitis/HIV etc)

Are you taking any medication? If yes, please list.

Date

Field label

By checking this box, I am stating that all the above information is true and correct.

03 9551 7684
0409 965 465

03 5968 2626
0409 965 465

PATIENT DETAILS FORM

Patient Details Form

03 9551 76840409 965 465

03 5968 2626 0409 965 465

PATIENT DETAILS FORM

Patient Details Form

03 9551 7684
0409 965 465

03 5968 2626
0409 965 465