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Health & Dental Declaration

Please answer the following to the best of your knowledge

Emergency Contact Information

Health Declaration

Are you under the care of a physician?
Were you hospitilized in the last 12 mos?
Please check the choices below if you currently have, or have had any of the following health conditions
Do you smoke or use tobacco products?
Are you pregnant?
Have you recently had a fluctuation in weight?
Do you frequently experience indegistion?

Dental Declaration

Have you ever had a tumor in the head, neck or mouth?
Have you visited a dentist in the past 12 months?
Choose all that apply
How often do you brush your teeth?
Have you had X-rays done in the past 2 years?
What type of dentures do you have?
What type of dentures do you have?

More about your dentures (if applicable)

Are you happy with the appearance?
Problems eating/biting
Do you soak your dentures in a solution?
Do you use denture adhesives?
Are you happy with the fit?
Do you get sores?
Problems speaking
Do you brush your dentures?
Do you brush your gums?
Sleep with dentures in?
Interested in dental implants?
Are you aware of the benefits of denal implants?

Thanks for submitting!

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