P. Rowatt | PM Denture Clinic, Hamilton | Denture Fitting & Repairs

Name *

Email Address *

Phone Number *

Preferred Date *

Pages (Hidden Field)

Present Denture Complaint *BrokenIll FittingNeeding Changed

Your Last Dental Visit

How old are the dentures you are wearing?

How is the fit?

Have you ever rejected a denture?YesNo

Do you wear a fixative?YesNo

Doctors Name

Surgery Address

Do you have or do you suffer from any of the following?

Dry MouthYesNo

UlcersYesNo

HeadachesYesNo

Cold SoresYesNo

Biting Tongue / CheekYesNo

Are you aware of Dental Implants?YesNo

Have you suffered from or are being treated for any of the following?

Any blood related diseaseYesNo

AnginaYesNo

If so do you carry your nitro?YesNo

Any serious operations in the last year?

Asthma or Chest infections?

DiabetesYesNo

Are you allergic to any substances?

Do you suffer from Epilepsy?YesNo

Do you carry a warning card?YesNo

Have you any signs of Covid 19?YesNo

Have you been inoculated against Covid 19?YesNo

Do you smoke?YesNo

If so how many a day?

Do you drink alcohol?YesNo

If so how often?

Thank you.

Please click Submit below to complete your appointment request.

We will be in touch to confirm your appointment.