15A - 8787 Weston Rd, Woodbridge, Ontario, L4L 0C3, Canada

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Sommer Denture Centre

15 - 8787 Weston Rd, Woodbridge, Ontario, L4L 0C3, Canada

Sommer Denture Centre

HOME
ABOUT
- ANDY SOMMER
PATIENT INFORMATION
- NEW PATIENT FORM
- DENTURE TECHNOLOGY
OUR SERVICES
AT HOME CARE
BLOG
CONTACT US

New Patient Form

Patient Information

Patient Information

First Name

Last Name

Patient Email

Phone Number

Date of Birth

How did you hear about us?

Emergency Contact

Emergency Contact

Emergency Contact Name

Emergency Contact Number

Emergency Relationship

Address

Address

Street Address

Unit

City

Province

Postal Code

Country

Insurance Information

Insurance Information

Do you have dental insurance?

If yes, please complete the following questions. If no. move onto Medical History

Enter your free text here

Insurance Company Name

Certificate / ID Number

Policy Number

Policy Holder Full Name

Policy Holder D.O.B

Medical History

Medical History

Family physician name

Family physician number

Date of last doctor visit

Dentist name

Dentist number

Date of last dental visit

Have you had dental x-rays taken within the last 2 years?

Do you have any following of the illness?

Heart disease

High blood pressure

Hepatitis A/B/C

New option

Cold sores

Mouth cancer

have had radiation or chemotherapy

HIV or AIDS

New option

Epilepsy or seizures

Tuberculosis

Diabetes

Stroke

Jaundice

Asthma

Sinus Trouble

Snoring

Thyroid disorder

Arthritis

Digestive disorder

Kidney disease

Gastrointestinal disorder

Bleeding disorder or bruise easily

Respiratory Disease

Rheumatic fever

Do you have any of the following conditions?

Facial muscle tenderness

Jaw joint clicking, popping or locking

Option 3

Earaches

TMDS (jaw pain)

Neck or shoulder pain

Hearing loss

Lumps or sore in your mouth

Teeth grinding

Sore or tending gums

Snoring

Burning sensation on your lips or tongue

New option

Dry mouth

Cardiac pacemaker

Heart Murmur

Fainting spells

Anxiety

Tumors or growths

Circulator issues

Anemia

Do you suffer rom any illness or condition not listed? please list)

Are you allergic to latex?

Are you allergic to metals?

Are you allergic to acrylic?

Please list all medications you are currently taking

Please list all major injuries and surgeries in the last 10 years

Denture History

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 How Can We Help

Enter your free text here

When was your last service?

How old are your dentures?

Less than a year ago

1-2-years ago

2-3-years ago

3+ years ago

How Can We Help

How Can We Help

How Can We Help

Complete Dentures

Partial Dentures

Denture Implants

Denture R

Immediate Dentures

Denture Liner

Custom Sport or Night Guard

Space

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We will get back to you as soon as possible.

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Request Your Next Denture Appointment

We look forward to seeing you soon!

Please note we will try our best to accommodate your schedule.

Full Name

Phone Number

Email

When would you like to come?

What time of day is better for you?

Do you have dental insurance?

Please provide more information. How can we help?

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We will get back to you as soon as possible.

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HOME
ABOUT
PATIENT INFORMATION
OUR SERVICES
AT HOME CARE
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CONTACT US

Contact Information

Phone:

Email:

info@sommerdenturecentre.com

Address:

15 - 8787 Weston Rd, Woodbridge, Ontario, L4L 0C3, Canada

Business Hours

Mon - Thu 8:00 am - 5:00 pm

Fri: 8:00 am - 2:00 pm

Sat - Sun Appointment Only

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