Letter Of Reservation To Attend Demostration Form – Fill Out and Use This PDF

The Letter of Reservation to Attend Demonstration form is a crucial document for individuals planning to attend a demonstration, outlining their intent and reserving a spot. This form usually includes personal information, reasons for attending, and any specific needs or accommodations required by the attendee. To ensure your participation is confirmed and tailored to your requirements, click the button below to fill out the form.

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Letter Of Reservation To Attend Demostration Form PDF Details

When planning to attend a demonstration, it's crucial to provide comprehensive information to ensure a seamless experience. The Letter Of Reservation To Attend Demonstration form serves as an essential tool in this process, catering to the needs of attendees by capturing detailed patient history information. It begins with the basics such as the patient's name, contact details, and demographic information, ensuring that every participant is accounted for meticulously. Crucial health details such as allergies, past medical history including surgeries, reactions to medications, and chronic conditions are thoroughly inquired about to ensure the safety and well-being of all attendees. Additionally, the form explores the patient's dental history, inquiring about dentures, use of dental adhesives, and previous dental treatments, which could be critical during the demonstration. Information regarding how the patient discovered the affiliated dental practice suggests an interest in understanding the effectiveness of various marketing channels. The option for patients to receive information on denture products or services indicates a personalized approach to patient care. Furthermore, financial aspects are not overlooked, with questions regarding dental insurance and payment policies outlined to ensure clarity and preparedness ahead of the demonstration. This meticulous approach underscores the importance of detailed planning and personalized care in preparing for a dental demonstration, ensuring that each participant's needs and safety are prioritized.

Question	Answer
Form Name	Letter Of Reservation To Attend Demostration Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	affordable dentures application, affordable dentures greenville nc, affordable dentures, affordable dentures patient history form

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An Afﬁliated Practice Providing

PATIENT

HISTORY INFORMATION

Patient ID #

For office use:

Name:____________________________________________________________________________________________


	(first name)	(middle name)		(last name)
Sex: _____M_____F	Date of Birth: ______/______/______		Social Security Number: _______		- _____ - _______
Street Address:_______________________________________________________________________________________
City:______________________________________		State:___________________________________			Zip:____________

E-Mail: _______________________________ Home Phone:___________________ Work Phone:_____________________

Cell:_______________________		Emergency Contact Name & Phone:___________________________________________
Race:	___African American	___Asian American	___Caucasian/White	___Hispanic	___Other

Name of Family Physician: _______________________________________ City:______________________ State:_______

PLEASE ANSWER THE FOLLOWING QUESTIONS:

*What is your reason for today’s visit?_____________________________________________________________

_____________________________________________________________________________________________

*	Have you received treatment in our office previously? YES NO If so, when?_____________________

*How did you first learn about our affiliated dental practice providing Affordable Dentures? (circle one)

	1.	Magazine	2.	Newspaper	3.	Radio	4.	Billboards/Sign			5.	Brochure/Mail
	6.	Television	7.	Yellow Pages	8.	Friend/Relative	9.	Internet/Web Site			10.	Other Doctor
	11.	Outside Agency
*	Did you call our toll-free information service (1-800-DENTURE)								YES	NO
*

*May we provide your name to denture product companies who may wish to send you

information on their products?

YES

*May we contact you with information about special offers and new services we may offer at

Affordable Dentures? YES

If answer is YES, what is the best way to contact you?

(Please circle all methods of communication that you prefer below.)

MAIL		PHONE	EMAIL

Do you have commercial dental insurance?	YES	NO	Name of Insurance:___________________________

If yes, we will provide you with a special statement of services for use when you submit your claim.

STANDARD 1/6/12

YES	NO	Are you currently wearing dentures? If yes, when did you receive your last dentures?_______________
YES	NO	Do you use denture adhesives, paste or powder? If so, please describe__________________________

* HAVE YOU EVER HAD...

YES	NO	Teeth extracted? If so, when:_________________
		Any problems?______________________________________________________________________
YES	NO	Bleeding problems?
YES	NO	Bad reaction to anesthesia (Novocaine?)
YES	NO	Allergic reaction to medications? (Penicillin or Codeine)
		Please circle and/or specify:___________________________________________________________
YES	NO	Allergic reaction to latex? Please specify:_________________________________________________
YES	NO	A heart attack or heart problems?
		Please specify:__________________________________________________ If so, when:__________
YES	NO	Prosthetic (false) joints, knee, hip, or valves?
		Please specify. ______________________________________________________________________
YES	NO	Circulatory problems?
YES	NO	Tuberculosis or other chronic ailments? For example Chronic Obstructive Pulmonary Disease or C.O.P.D.
		Please specify:______________________________________________________________________
YES	NO	Hepatitis or liver disease?
YES	NO	Diabetes or kidney failure?
YES	NO	Rheumatic fever or heart murmur?
YES	NO	A stroke? If so, when:______________________________
YES	NO	High or low blood pressure? Please circle and/or specify:_____________________________________
YES	NO	Cancer? Where?_______________________Radiation?________ Chemotherapy?______
YES	NO	Immune system disorder or infection including HIV ?
YES	NO	Fainting spells or seizures?


YES	NO	Do you take ASPIRIN daily?
YES	NO	Are you taking birth control pills or using other hormonal birth control method
		(For example, Norplant)? Please specify:_______________________________________________
YES	NO	Are you taking, or have you ever taken prescription medication for osteoporosis (bone loss)?
		(For example, FOSAMAX)? Please specify:____________________________________________
YES	NO	Are you pregnant or nursing?
YES	NO	Do you smoke or use tobacco products?
YES	NO	Do you use illegal drugs (For example marijuana or cocaine)?
YES	NO	Do you have any sores in your mouth?
Please list any medicines you currently take			_____________________________________________________________
(including Herbal Supplements):			_____________________________________________________________
Other Comments:			_____________________________________________________________

To the best of my knowledge the above questions have been answered accurately. I understand that the fee for dentures,

extractions, and other services must be paid on the first visit after you are seen by the dentist.

PATIENT SIGNATURE:_______________________________________________________Date:____________________

OUR PAYMENT POLICY

We gladly accept payment by cash, MasterCard, Visa and Discover.

Some offices are able to accept checks with identification.

You will need to check with the office you are visiting to confirm their payment policies.

Letter Of Reservation To Attend Demostration Form – Fill Out and Use This PDF

Letter Of Reservation To Attend Demostration Form PDF Details

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