Appointment Request Appointment Request Patient Information Patient First Name Patient Last Name Patient is Residing in Apartment House Dementia Unit Mental Health Facility Seniors Lodging Hospital Other Institution Not Listed Lives 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 Bound Wheelchair Bound Too Tiring to Go Out No Mobility Issues, Just Like the Convenience & or Privacy Too 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 Dentures Dentures are Ill Fitting Dentures are Old & Worn Cannot Eat With Dentures Broken Dentures Dentures Require Relining Dentures are Painful Will be having one or more teeth extracted A combination of one or more of the above scenarios Financial Who is responsible for this account? Alberta Senior Benefit AISH Social Services I have a voucher Public Trustee Family Trust Account at Building Self Other 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
