Appointment Request Appointment Request Patient Information Patient First Name Patient Last Name Patient is Residing in ApartmentHouseDementia UnitMental Health FacilitySeniors LodgingHospitalOther Institution Not ListedLives with Family Patient Address (Unit, Room, Apt, Buzzer, City & Postal Code) Building Name Patient Phone Number (including area code) Any Scheduling Restrictions Mobility Issues Bed BoundWheelchair BoundToo Tiring to Go OutNo Mobility Issues, Just Like the Convenience & or PrivacyToo Difficult for Family to Take to Appointments Contact Information Your Name Relation to Patient If Healthcare Professional, Your Title Are you contacting us from a facility? Yes No Contact Email Address Contact Phone Number (including area code) Does the Contact need to be present for the appointment? Yes No Current Denture Problems Lost DenturesDentures are Ill FittingDentures are Old & WornCannot Eat With DenturesBroken DenturesDentures Require ReliningDentures are PainfulWill be having one or more teeth extractedA combination of one or more of the above scenarios Financial Who is responsible for this account? Alberta Senior BenefitAISHSocial ServicesI have a voucherPublic TrusteeFamilyTrust Account at BuildingSelfOther Do you want us to check insurance for you? Yes No Please provide the following information: Patient Date of Birth Patient Alberta Health Care Number (if applicable) AISH Number (beginning with X; if applicable) Social Services Number (if applicable) reCAPTCHA If you are human, leave this field blank. Δ Thank you for your interest in our company. HOURS Monday – Friday 9:00 AM – 5:00 PM Extended Hours Available
