Labrador Denture Clinic
 
 
 
 
The oldest fourth generation family owned Denture Clinic on the Gold Coast
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FOR GOOD LOOKING COMFORTABLE DENTURES THAT WORK, GO WHERE THE LOCALS GO
 
 
 
CALL US TODAY
(07) 5529 1411
 
 
 
 
 

FORMS

 

PATIENT INFORMATION FORM

 
Personal Info
 
Name *
 
 
 
 
 
 
 
 
 
 
 
 
Date of Birth *
 
 
Address *
 
 
 
 
 
 
 
 
 
 
 
 
 
Home Phone
 
 
Mobile
 
 
Email *
 
 
Emergency Contact Name & Relationship *
 
 
Emergency Contact Phone *
 
 
Medical History
 
Doctors Name
 
 
Practice Name
 
 
Suburb
 
 
Which health fund are you with, if any
 
 
DVA Number (if applicable)
 
 
Are you taking any medications?
please list medications
 
 
Do you have any allergies
 
 
Have you ever suffered from?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do you smoke?
 


 
Denture History
 
What is the main purpose of your visit?
 
 
Name of your dentist?
 
 
When was your last dental exam?
 
 
How old are your current dentures?
 
 
Are you happy with the appearance of your current dentures?
 


 
Are your dentures ill fitting?
 


 
Do you have difficulty chewing your food?
 


 
Do you have any pain or discomfort now?
 


 
How many sets of dentures do you have?
 
 
How did you hear about Labrador Denture Clinic?
 







 
Message
 
 
 
 
 
 

 

Aged Care Resident Referral Form

 
Personal Info
 
Resident Name *
 
 
 
 
 
 
 
 
 
 
 
 
Date of Birth *
 
 
Next of Kin / Person Responsible For Account *
 
 
Contact Number *
 
 
Contact Email *
 
 
Facility Name *
 
 
Facility Address *
 
 
 
 
Facility Contact Person *
 
 
Facility Contact Number *
 
 
Reason for Referral?
 





 
Yes, Our Facility is interested In