New Patient Forms | Odyssey Dental Care

Patient Information

First Name *

Last Name *

Date of Birth *

Gender *

Male

Female

Address (Unit No., Street No., Street Name, City, Province, Postal Code) *

Phone Number *

Email Address *

Occupation *

Are you likely to be available on short notice for future appointments or changes? *

Yes

No

We would like to send you email and text communications which may include appointment confirmations, newsletters, upcoming events, and important notifications. Check Yes or No if you'd like to receive future email and text communications from us. *

Yes

No

How did you hear about us? *

Other (Please specify)

Emergency Contact's First Name *

Emergency Contact's Last Name *

Emergency Contact's Phone Number *

Relationship to Emergency Contact *

Dental Information

In the following sections, please select whichever applies. Your answers are for our records only and will be kept confidential in accordance with applicable laws. Please note that during you initial visit you may be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.

Do your gums bleed while brushing or flossing? *

Yes

No

Do you bite your lips or cheeks frequently? *

Yes

No

Have you ever had orthodontic (braces) treatment? *

Yes

No

Do you get headaches or migraines? *

Yes

No

Are your teeth sensitive to cold, hot, sweets or pressure? *

Yes

No

Have you had any difficult extractions in the past? *

Yes

No

Do you feel pain to any of your teeth? *

Yes

No

Have you ever worn a bite plate or other appliance? *

Yes

No

Do you have any sores or lumps in or near your mouth? *

Yes

No

Have you ever had difficulty opening or closing jaw? *

Yes

No

Have you ever had a head, neck or jaw injury? *

Yes

No

Have you had any pain in your jaw area? *

Yes

No

Do you have any loose teeth or have they ever shifted? *

Yes

No

Have you ever had periodontal treatment (gums treatment)? *

Yes

No

Does food frequently get caught in your teeth? *

Yes

No

Please give a brief description of your oral hygiene habits. *

If you have a current dental problem, please describe.

Do you have any other concerns about having dental treatment? *

Yes

No

If yes, please explain.

Do you ever feel nervous about visiting the dentist? *

Yes

No

If yes, please explain.

Are you happy with the appearance of your teeth? *

Yes

No

If no, please explain.

Date of your last dental x-ray (if applicable)

Date of your last teeth cleaning (if applicable)

Please provide your previous dentist's name.

What can we do to make you smile? Check all that apply, and we'll get back to you as soon as possible with more information about your inquiry.

Veneers

Gummy Smile

White Fillings

Oral Conscious Sedation

Total Smile Reconstruction

Replace Metal Fillings

Neuromuscular Dentistry

Replace Missing Teeth

Correct Misaligned Teeth

Orthodontics

Dentures

Sleep Apnea/Snoring

Broken/Cracked Teeth

Rejuvenate Worn/Stained Teeth

Dental Implants

Eliminate Gaps

Invisalign® Teeth Straightening

Medical Information

Dental professionals primarily treat the area in and around your mouth, but since your mouth is part of your body, any medication you are taking and your health history have a important relationship with your dental treatment. Please answer the following questions.

Are you currently seeing a Family Physician? *

Yes

No

If yes, please enter the physician's name, phone number, and date of last visit.

Have you recently (in the last two years) been hospitalized or had a major operation? *

Yes

No

If yes, please explain.

Have you ever had a serious head or neck injuy? *

Yes

No

If yes, please explain.

Are you taking birth control pills (if applicable)? *

Yes

No

Not applicable

Are you or could you be pregnant (if applicable)? *

Yes

No

Not applicable

If yes, what is the expected delivery date?

Please provide the date of your last physical exam (if applicable).

Please go over the following section and answer the following questions.

AIDS/HIV Positive *

Yes

No

Chest Pains *

Yes

No

Hemophilia *

Yes

No

Alzheimer's Disease *

Yes

No

Circulation Problems *

Yes

No

Hepatitis A *

Yes

No

Hepatitis B *

Yes

No

Hepatitis C *

Yes

No

Anaphylaxis *

Yes

No

Diabetes *

Yes

No

Anemia *

Yes

No

Emphysema *

Yes

No

High Blood Pressure *

Yes

No

Arthritis/Gout *

Yes

No

Epilepsy/Seizures *

Yes

No

Kidney Problems *

Yes

No

Artificial Heart Valve *

Yes

No

Fainting *

Yes

No

Liver Disease *

Yes

No

Artificial Joint *

Yes

No

Glaucoma *

Yes

No

Lung Disease *

Yes

No

Asthma *

Yes

No

Head or Neck injuries *

Yes

No

Mental/Nervous Disorder *

Yes

No

Blood Disease *

Yes

No

Heart Attack/Failure *

Yes

No

Organ/Medical Transplant *

Yes

No

Bruise Easily *

Yes

No

Heart Murmur *

Yes

No

Sickle Cell Disease *

Yes

No

Cancer *

Yes

No

Heart Pacemaker *

Yes

No

Stroke *

Yes

No

Chemotherapy *

Yes

No

Heart Surgery *

Yes

No

Tuberculosis *

Yes

No

Please list any prescription or non-prescription medicine you are currently taking or have recently taken.

If you have any allergic conditions, please list them. (This can include asthma, hay fever, food allergies, and metal or latex allergies.)

Are you allergic to or have you had a reaction to any of the following items?

Barbiturates, sedatives or sleeping pills *

Yes

No

Antibiotics *

Yes

No

Aspirin *

Yes

No

Codeine *

Yes

No

Darvon *

Yes

No

Local Anesthetic *

Yes

No

Nitrous Oxide *

Yes

No

Other, please specify.

Do you use any form of tobacco or are wearing a nicotine patch? *

Yes

No

Are you dependent on alcohol or drugs? *

Yes

No

If so, have you received treatment?

Yes

No

Have you ever tested HIV positive? *

Yes

No

For children only

At our office, all professional dentistry services are performed by licensed members of the Manitoba Dental Association (the "Dental Professionals"), and all institutional health care services are performed independently by Odyssey Health Services under the clinical supervision and control of Dental Professionals, in a cost-sharing arrangement. Odyssey Dental Care and Odyssey Health Services are independent corporations providing independent services, but for ease of administration they may render joint invoices for their respective services. One or more of our Dental Professionals has a financial interest in Odyssey Health Services. By signing this form, the undersigned acknowledges and agrees that they have read and understood the information and disclosure set forth herein prior to any professional services being provided to the undersigned by any Dental Professionals working with Odyssey Dental Care.

Please list any medical conditions or illnesses the child has recently had. (This can include measles, strep throat, tonsillitis, etc.)

Patient Consent

I hereby consent to the above and certify that the information provided is true and accurate to the best of my knowledge. *

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Patient Form for New Patients

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Patient Information

Dental Information

Medical Information

Patient Consent

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