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Patient Details Form | Emerald Denture Clinic

PATIENT DETAILS FORM

Please complete your details in the form below & select submit for your information to be sent to the Dental Prosthetist office.

Surname

First Name

Address

Suburb

State

Postcode

Date of Birth

Phone

Mobile No

Health Fund

Extra's

Yes No

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?

Are your current dentures loose?

Are you happy with their appearance?

Are your current dentures loose?

How long have you worn dentures?

How old are your current dentures?

Do you have a hearing impairment?

Do suffer from any of the following:

Dry Mouth Sore spots or leisons Denture discomfort Dental caries or plaque

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

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

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)

dATE

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

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CONTACT US

03 5968 2626
0409 965 465
smile@emeralddenture.clinic
396 Belgrave-Gembrook Rd,
Emerald VIC

03 5968 2626

0409 965 465

Patient Details Form | Emerald Denture Clinic

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