Affordabledentures.com

Name:____________________________________________________________________________________________ Sex: _____M_____F Date of Birth: ______/______/______ Social Security Number: _______ - _____ - _________________ Street Address:_______________________________________________________________________________________ _____________________________________________________________________________________City:______________________________________ State:___________________________________ Zip:____________ E-Mail: _______________________________ Home Phone:___________________ Work Phone:_____________________ Cell:_______________________ Emergency Contact Name & Phone:___________________________________________ Race: ___African American ___Asian American ___Caucasian/White ___Hispanic ___Other__________Name of Family Physician: _______________________________________ City:______________________ State:_______ What is your reason for today’s visit?_____________________________________________________________ _____________________________________________________________________________________________ Have you received treatment in our office previously? YES NO If so, when?_____________________ How did you first learn about our affiliated dental practice providing Affordable Dentures? (circle one) 1. Magazine 2. Newspaper 3. Radio 4. Billboards/Sign 6. Television 7. Yellow Pages 8. Friend/Relative 9. Internet/Web Site 10. Other Doctor Did you call our toll-free information service (1-800-DENTURE) YES NO May we provide your name to denture product companies who may wish to send you May we contact you with information about special offers and new services we may offer at Affordable Dentures? YES NO If answer is YES, what is the best way to contact you? (Please circle all methods of communication that you prefer below.) Mail Phone Email
Do you have commercial dental insurance? YES NO Name of Insurance:___________________________ If yes, we will provide you with a special statement of services for use when you submit your claim.
NO Are you currently wearing dentures? If yes, when did you receive your last dentures?_______________ Do you use denture adhesives, paste or powder? If so, please describe__________________________ Teeth extracted? If so, when:_________________ problems?______________________________________________________________________ Allergic reaction to medications? (Penicillin or Codeine) Please circle and/or specify:___________________________________________________________ Allergic reaction to latex? Please specify:_________________________________________________ Please specify:__________________________________________________ If so, when:__________ Prosthetic (false) joints, knee, hip, or valves? Please specify. ______________________________________________________________________ Tuberculosis or other chronic ailments? For example Chronic Obstructive Pulmonary Disease or C.O.P.D.
Please specify:______________________________________________________________________ A stroke? If so, when:______________________________ High or low blood pressure? Please circle and/or specify:_____________________________________ Cancer? Where?_______________________Radiation?________ Chemotherapy?______ Immune system disorder or infection including HIV ? Are you taking birth control pills or using other hormonal birth control method (For example, Norplant)? Please specify:_______________________________________________ Are you taking, or have you ever taken prescription medication for osteoporosis (bone loss)? (For example, FOSAMAX)? Please specify:____________________________________________ Do you use illegal drugs (For example marijuana or cocaine)? Please list any medicines you currently take _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ To the best of my knowledge the above questions have been answered accurately. I understand that the fee for dentures, extractions, and other services must be paid on the first visit after you are seen by the dentist. PATIENT SIGNATURE:_______________________________________________________Date:____________________ We gladly accept payment by cash, MasterCard, Visa and Discover. Some offices are able to accept checks with identification. You will need to check with the office you are visiting to confirm their payment policies.

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