(403) 263-9014

East Village Dental

(403) 263-9014
526 Riverfront Ave SE,
Calgary, Alberta T2G 1E4

Adult New Patient Intake Form

Adult New Patient Intake Form

Patient’s information

The following information is required by East Village Dental to assist in proper diagnosis and treatment. Please feel free to ask our receptionist for help completing this form.
Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal

Emergency Contact

Name
Name
First
Last

This information greatly helps us.
Financing Options

Person Responsible for Payment

Info of person responsible for payment of account (if different from above)
Emergency Contact Name
Emergency Contact Name
First
Middle
Last
Address
Address
City
State/Province
Zip/Postal

Medical History

What is your estimate of your general health?

Section

General
Reactions
Female Specific

Specific History

Do you, or have you had, any of the following:
Reactions

Medications

List all medications, supplements, and or vitamins taken within the last two years

Please advise us in the future of any changes in your medical history or any medications you may be taking.

Dental History

Personal History

Are you fearful of dental treatment
Have you had an unfavorable dental experience
Have you ever had trouble getting numb or had any reactions to local anesthetic
Did you ever have braces, orthodontic treatment or had your bite adjusted

Gum and Bone

Do your gums bleed or are they painful when brushing of flossing
Have you ever been treated for gum disease or been told you have lost bone around your teeth
Did you ever have braces, orthodontic treatment or had your bite adjusted
Have you ever experienced gum recession

Tooth Structure

Do you feel or notice any holes, i.e. pitting or craters, on the biting surface of your teeth
Do you have grooves or notches on your teeth near the gum line
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling
Do you frequently get food caught between any teeth

Bite and Jaw Joint

Do you have problems with your jaw joint? pain, sounds, limited opening, locking, popping
Do you feel like your lower jaw is being pushed back when you try to bite your teeth back together
In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed
Are your teeth becoming more crooked, crowded, or overlapped
Do you have trouble finding your bite, need to squeeze/tap your teeth together, or shift your jaw to fit teeth together

Airway and Sleep

Do you snore or have been told you do?
Have you been told you stop breathing during sleep
Have you been diagnosed or treated for a sleep disorder
Do you use a CPAP device or an oral sleep appliance

Smile Characteristics

Is there anything about the appearance of your teeth that you would like to change (shape, color, size)
Have you ever whitened (bleached) your teeth
Have you ever felt uncomfortable or self conscious about the appearance of you teeth
Have you ever been disappointed with the appearance of previous dental work

Are you interested in, or have you thought about any of the following:

Have you ever been sedated? If yes, select which types of sedation you’ve previously had.
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Working Hours

Monday 8AM to 8PM
Tuesday 8AM to 8PM
Wednesday 8AM to 8PM
Thursday 8AM to 8PM
Friday 8AM to 4PM
Saturday 830AM to 4PM
Sunday CLOSED

* Limited availability on holidays.

(403) 263-9014

526 Riverfront Ave SE,
Calgary, Alberta T2G 1E4

Schedule
Appointment