New Denture Patient Intake | Ottawa Valley Denture Clinic | Clinic Forms

Ottawa Valley Denture Clinic

Step 1 of 4 - Patient Information

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NEW PATIENT INTAKE FORM

Patient information
Questions marked with a* are required. Questions you are unsure of or would prefer to answer verbally can be skipped.
Patient Name*
First Last
Preferred Name / Nickname
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Date of birth*
MM slash DD slash YYYY
Home Phone*
Mobile Phone*
Email
Emergency contact name*
First Last
Phone*
Email
Relationship
Do you have dental insurance?
- Yes
- No
Insurance information
Primary insurer
Insurance company
Certificate/ID number
Group/Policy number
Are you a dependant?
- Yes
- No
Name of insurer
First Last
Insurer date of birth
MM slash DD slash YYYY
Relationship
Secondary insurer
Insurance company
Certificate/ID number
Group / policy number
Are you a dependant?
- Yes
- No
Name of insurer
First Last
Insurer date of birth
MM slash DD slash YYYY
Relationship
Canadian Dental Care Program (CDCP)
Member ID
Coverage start date
As per welcome package.
MM slash DD slash YYYY
How did you hear about our clinic?
- Internet search
- Dentist
- Social media
- Referral
- Newspaper or print ad
- Friend
- Sign

NEW PATIENT INTAKE FORM

Medical history
Do you have a family physician?*
- Yes
- No
Name
First Last
Phone
Do you have a dentist?*
- Yes
- No
Name
First Last
Phone
Are you being treated for any medical conditions at present or within the past 5 years?
- Yes
- No
Please explain:
Have you been injured or hospitalized in the last 2 years?
- Yes
- No
Please explain:
Are you presently taking any prescription/non-prescription medications?
- Yes
- No
Please list your medications or write "NONE" in the box. **If you have a long list, please bring it to your appointment.
Do you experience dry mouth with or without medication?*
- Yes
- No
Which of the medical conditions apply to your family history?
- Diabetes
- Heart disease
- Cancer
- Osteoporosis
- None
Have you ever had head, facial, jaw or neck trauma?*
- Yes
- No
Do any of the following conditions apply to you?
- Facial muscle tenderness
- Joint clicking, popping or locking
- Migraines or headaches
- Earaches
- TMJ (Jaw) pain
- Neck or shoulder pain
- Hearing issues
- Lumps or sores in your mouth
- Grind your teeth
- Sore or tender gums
- Snoring
- Burning sensation on your lips or tongue
- Gasp or stop breathing in your sleep
- Bleed excessively from a cut
- Bruise easily
- Other
Additional condition details:
Has your weight, appetite, or energy level changed dramatically recently?*
- Yes
- No
Do you follow a special diet?*
- Yes
- No
Do you smoke?*
- Yes
- No
How much do you smoke?
Are you allergic to any of the following?
- Acrylic
- Latex
- Metal
- None
Please specify any other allergies:
Have you ever had or are going through radiation or chemotherapy?*
- Yes
- No
When was your last radiation or chemotheraphy treatment?
YYYY slash MM slash DD
Do you have memory issues?
- Yes
- No
Do you wear hearing aids?
- Yes
- No
Who is your care provider? (Audiologist/Hearing Instrument Specialist)
Do you have cochlear implants?
- Yes
- No
Do you have any of the following?
- Anemia
- Alzheimer's/Dementia
- Arthtritis
- Asthma
- Blood Transfusion
- Cancer
- Cold Sores
- COPD
- Diabetes
- Drug Addiction
- Emphysema
- Epilepsy or Seizures
- Fibromyalgia
- Heart Condition
- Heart Disease
- Hepatitus A/B/C
- High Blood Pressure
- High Cholesterol
- HIV or AIDS
- Hyper/Hypoglycemia
- Jaundice
- Low Blood Pressure
- Lupus
- Mouth Cancer
- Osteoporosis
- Parkinson's Disease
- Rheumatic fever
- Sexually Transmitted Infection (STI)
- Sinus Trouble
- Stroke
- TMJ Disorder
- Thrush
- Thyroid Disorder
- Tuberculosis
- Other
Please list other illnesses:
Is there anything the denturists should know about your health?

NEW PATIENT INTAKE FORM

Denture/Dental History
How many dentures have you had?
Do you have a full denture?
- Full upper denture
- Full lower denture
- Full upper and lower denture
- None
How old is your full denture?
When was the last reline?
Do you have partial dentures?
- Partial upper denture
- Partial lower denture
- Partial upper and lower dentures
- None
How old are your partial dentures?
When was the last reline?
Do you have dental implants?
- Yes
- No
Do you have any remaining natural teeth?
- Upper
- Lower
- Upper and lower
- None
Do you grind or clench your teeth?
- Yes
- No
When was your last visit to your dentist?
Do you require dental work?
ie. cleaning, fillings, extractions
- Yes
- No
- Not Sure
Do you chew well with your dentures?
- Yes
- No
Do you wear your dentures at night?
- Yes
- No
Are your dentures loose?
- Yes
- No
Which denture is loose?
- Upper
- Lower
- Both
Are your dentures comfortable?
- Yes
- No
Do you get food under your dentures?
- Yes
- No
Which denture?
- Upper
- Lower
- Both
Do you gag easily?
- Yes
- No
Do you chew mints or gum?
- Yes
- No
Do you have digestive issues?
- Yes
- No
Who made your current dentures?
- Denturist
- Dentist
Are you happy with your current dentures?
- Yes
- No
- Somewhat
What are your concerns with your current dentures?

NEW PATIENT INTAKE FORM

Consent
I consent to have treatment by my denturist at Ottawa Valley Denture Clinic (OVDC).

I consent to have my dentist or physician contacted if additional dental/medical information is required for my dental care.

I understand that this clinic does not accept assignment of benefits, and OVDC will not submit to or claim from insurance companies. Any claim forms will be printed off and provided to the patient at the completion of service.

I assume responsibility for all fees incurred. All fees not covered by my insurance company is my responsibility.

We understand that circumstances change and we ask to be notified at least 24 hours in advance. This allows us to manage our schedule effectively and offer the time slot to another patient in need. Failing to show up for your scheduled appointment without prior notice will result in a fee of $75. We appreciate your understanding and cooperation in ensuring we can provide timely and efficient care to yourself and all our patients. Please note we consider exceptions for unavoidable emergencies on a case-by-case basis.
Consent*
I have read and understand the statements above and certify that the medical and dental information I provided is accurate to the best of my knowledge. I have not knowingly omitted any information.*
Consent*
I confirm that I will inform the staff of OVDC if I have qualified for government-funded programs, such as the Canadian Dental Care Program (CDCP), before starting treatment and making payment, and if there have been any changes to my eligibility status and coverage.*
Name of person filling out this form
First Last
Signature*
Phone
This field is for validation purposes and should be left unchanged.

Ottawa Valley Denture Clinic
186 Pembroke Street West,
2nd Floor
Pembroke, ON K8A 5M8

613-735-4034
[email protected]