New patient form

Prepare for your first visit.

Complete the form before your appointment, then print it or save it as a PDF. Bring the completed form with your ID, insurance details, and any current denture appliances.

Patient information

Full name

Date of birth

Phone

Home address

Emergency contact

Contact name

Contact phone

Relationship to patient

Coverage and referral details

Insurance, CDCP, or coverage notes

Referred by

Interested in direct billing Canadian Dental Care Plan (CDCP) Would like a treatment estimate

Denture and dental history

Complete dentures Partial dentures Implant-supported dentures Repair or adjustment First denture consultation Upcoming or recent extractions

Main concerns or goals

Health notes

Medical conditions the clinic should be aware of

Current medications

Allergies

Consent

I confirm the information above is accurate to the best of my knowledge and understand South Centre Denture Clinic may use it to support assessment and appointment planning.

Patient or guardian signature

Date

Prepare for your first visit.

South Centre Denture Clinic New Patient Form