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Intake Form

Please fill out the e-form below.

Present Denture Age:


1. Are you in good health at the present time?
2. Are you under the care of a physician at the present time?
3. Are you on any medications at the present time?
4. Are you allergic to any medications?
5. Is there any history of family disease? What?
6. Do you have or have you had any of the following conditions? (PLEASE CHECK APPLICABLE CONDITIONS)
7. Do you smoke or use chewing tobacco?
8. Have you ever had an x-ray for a tumor of growth in your head, neck, or mouth?
9. Have you had serious injury, surgery, or therapy to your head, neck, or mouth?
10. Do you bruise easily or bleed abnormally?
11. Are you pregnant?
12. Have you had a recent change in weight? If yes, how much?
13. Are you on a diet?
14. Do you have any habits that may affect your teeth, such as clenching, grinding, nail-biting, etc?

I, the undersigned, hereby certify the information given by me to be accurate, and I assume responsibility for all fees incurred.

Patient Signature:

Personal Information Protection Act Consent Form  

In our office, we are dedicated to ensuring the protection of our patient's personal information and ensuring that this information is used only in a professional manner. The following indicates some of the information that is collected, why we collect it, and when we may disclose your personal information. We collect, use, and disclose your personal information where permitted or required by law.

Contact Information

We collect contact information from our patients, such as full name, home address, home telephone number(s), work telephone number(s), and cellular phone number(s). This information is considered Contact Information and it is collected for a variety of purposes 'including the following:

  • To open and update a patient file;

  • To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts;

  • To process claims for payment or reimbursement from a third-party health benefit provider or insurance company*

  • To correspond by mail or by telephone to our patients regarding the need for further examination or treatments and

  • To send correspondence to our patients regarding our clinic and practice.

*Contact Information is/may be disclosed to a third-party health benefits provider or insurance company when submitting a claim on the patient's behalf, for payment or reimbursement of all or part of the cost of the treatment provided, or when a patient has requested a preauthorization of a proposed treatment.

Medical/Dental History 

We collect from our patients information about their health history, family health history, physical and mental condition, their dental health history, and family dental health history. This Medical/Dental information is collected for a variety of purposes and may be used in part to assist us in diagnosing dental conditions and providing appropriate treatment for you. and may be disclosed for the following purposes:


  • To a third-party health benefit provider or insurance company, in the submission of a claim on behalf of the patient, for reimbursement of payment of all or part of the cost of the treatment;

  • To a third-party health benefit provider or insurance company on behalf of the patient in the submission of a preauthorization of treatment;

  • To other health/dental providers where, upon your consent, we are seeking a second opinion;

  • To other health/dental providers where, upon your consent, we have referred you to additional/alternative treatment.

Future Use

If consideration to sell this practice or a portion of this practice ever occurs, qualified potential purchasers may be granted access as part of the due diligence process to patient information in order to verify information related to the sale. If this ever occurs, we will take the necessary steps to ensure that the prospective purchaser protects any personal information, as we have done.


The College of Alberta Denturists regulates all Denturists in the Province of Alberta and, as part of their regulatory function, may inspect our records and interview our staff in the process of their duties.


I hereby authorize and consent to the collection, use, and disclosure of personal information concerning myself with regard to the above purposes.

(Patient Signature)


Option 1— Regular Claim:


All accounts are paid by you at the time of service, and the insurance Claim (if any) is sent electronically (when possible) by our office at the time of your appointment. The insurance payment is mailed directly to you and may be received in as little as three days.


I, the undersigned, hereby agree to the Financial Policy of Denture Clinic as outlined above.


Option 2 — Direct Billing:


For direct billing insurance providers, a credit card must be on file for outstanding amounts owing after insurance claims. Each insurance provider has fee guides to calculate your coverage. Insurance providers pay a percentage of their fee guide, not a percentage of our office fee guide. Because of this, it is impossible to estimate exactly how much your Insurance provider with reimburse you. We strive to accurately estimate reimbursement; however, there may be a balance owing. For balances owing under $100, your card will be automatically charged. For balances over $100, we will attempt to contact you and mail you a receipt with a copy of the Explanation of Benefits from your insurance provider.


I agree to the above financial policy and authorize Leduc Denture Clinic/River Valley Denture Clinic to apply any outstanding balance on my account, not covered by my insurance provider, to the credit card listed below:

Authorization Signature: 


I, the undersigned, authorize (Denture Clinic) to perform any necessary denture services that I may need during my diagnosis and treatment with my informed consent. I certify that the medical and dental histories provided are accurate and complete to the best of my knowledge. I also understand that any and all denture services are my sole responsibility and that I should make myself aware of any fees associated with my denture care prior to treatment.


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