T: 204-261-7798

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Patient Info
- Your First Visit
- New Patient Intake
Contact

Home
About
Services
Patient Info
- Your First Visit
- New Patient Intake
Contact

Marketview Dental New Patient Intake

As a new patient, we need some information to get things rolling.

Please fill out the form below to get started.

New Patient Intake

You may have some questions prior to filling in the new patient intake form, if so please give us a call or visit our contact page to get in touch with us with any questions you may have.

New Patient Intake

First Name

Last Name

Date Of Birth

Your Adress

Address Line 1

City

Province

Postal Code

Home Phone

Mobile Phone

Reminders Via Text:

Yes

If minor, name of parent or guardian:

First Name

Last Name

Whom may we thank for this referral?

First Name

Last Name

If you would like us to file insurance claims on your behalf, please provide us with the following information. Otherwise, payment is the patient’s responsibility on the day of service. Thank you.

Dental Insurance Information: (Please provide a copy of your Dental Insurance Card.)

Name of Policy Holder:

Policy / Group #:

Name of Insurance Company:

Certificate / ID / Contract#:

Emergency Contact Information:

First Name

Last Name

Relationship:

Home Phone

Cell Phone

Date of your last dental visit:

Date of your last complete dental X-Ray?

Medical History:

Have you been under the care of a medical doctor in the past 2 years?

Yes

Are you allergic to any medications? Please list

Are you a smoker?

Yes

Please list any medication you are currently taking:

Please check any of the following which you have had or currently have:

Heart Disease or Attack

Chest Pain

Tuberculosis

Asthma

Rheumatic Fever

Congenital Heart Lesions

Artificial Heart Valve

Heart Pacemaker

Heart Surgery

Artificial Joint

Anemia

Stroke

Kidney Trouble

Ulcers

Shortness of breath

Emphysema

Common Cold

Hepatitis A

Hepatitis B

Hepatitis C

Liver Disease

Hay Fever

Allergies or Hives

HIV Positive

Auto Immune Disease

Diabetes

Thyroid Disease

Arthritis

High Blood Pressure

Heart Murmur/Mitral Valve

Hemophilia

Cold Sores or Fever Blisters

Epilepsy

Are you having dental problems currently?

Yes

If yes, please explain:

Do you take pre-medication before dental treatments?

Yes

If yes, please explain:

Women, are you pregnant?

Yes

If yes, when are you due?

Are you breast feeding?

Yes

Additional Comments

OUR PRIORITY IS YOUR SMILE

CLINIC HOURS

Monday 8am - 5pm
Tuesday 10am - 8pm
Wednesday 8am - 5pm
Thursday 8am - 5pm
Friday Closed
Saturday Closed
Sunday Closed

CONTACT

T: 204-261-7798

marketviewdental@gmail.com

#100 - 3435 Pembina Hwy,
Winnipeg, Manitoba, R3V 0B8

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New Patient Intake
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T: 204-261-7798

Marketview Dental New Patient Intake

New Patient Intake

If minor, name of parent or guardian:

Whom may we thank for this referral?

If you would like us to file insurance claims on your behalf, please provide us with the following information. Otherwise, payment is the patient’s responsibility on the day of service. Thank you.

Emergency Contact Information:

Medical History:

Please check any of the following which you have had or currently have:

OUR PRIORITY IS YOUR SMILE

CLINIC HOURS

CONTACT

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