Help With This Form

Page 1 of LifeSmiles Dental Corp's Medical Form  

Title

Your title can include Mr., Mrs., Miss., Ms., Sir., Dr., etc. 

Name

Please include your full first and last name. 

Address

Please provide your mailing address including your postal code. 

Email

We recommend choosing an email address that you check regularly. 

Date of Birth

Your date of birth should be recorded in this format, "Month, Day, Year".

Phone and Phone Type

Please include the area code for your phone number. 

6 Digital Health Card Number

The 6 digital code can be found on your Manitoba Health Card and is your registration number. Please contact one of our dental offices if you need help locating the 6 digital code. 

9 Digital Health Card Number

The 9 digital code can be found on your Manitoba Health Card and is your Personal Health I.D No. Please contact one of our dental offices if you need help locating the 9 digital code. 

Occupation

An occupation can also be referred to as a job position. 

Employer

An employer can also be referred to as a business/company name. 

Emergency Contact Name and Phone Number 

We recommend choosing a close relative or friend that checks their phone regularly. 

How did you hear about our office? 

Possible methods can be Facebook, Instagram, Internet Search, Referral from a Friend, etc. 

Can we send you update, announcements, and promotions via email?

You can opt out of LifeSmiles Dental Corp's newsletter subscription at any time. 

Which LifeSmiles location would you like to be booked into? 

Please choose 1 of our 6 locations. LifeSmiles Dental Corp has dental offices in Winnipeg, La Salle, Selkirk, and Portage La Prairie. 

Page 2 of LifeSmiles Dental Corp's Medical Form

The second page of LifeSmiles Dental Corp's medical form will ask a series of questions related to your health. This includes, but isn't limited to your family physician's contact information, current medications, and past health problems. We ask that you try to answer these questions as accurately as possible. If you need further explanation, please contact one of our dental offices and a rep will be happy to help ​ 

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Page 3 of LifeSmiles Dental Corp's Medical Form  

Do you have any of the following? Please check all that apply. 

Please check all that apply. If this list does not apply to you, please skip it. If you are unsure if any of these options apply to you, please contact your family physician. 

Are there any conditions or diseases not listed that you have or had previously? 

All conditions and/or diseases are worth mentioning, no matter how minor or short you may think they are/were.

Do you smoke or chew tobacco products? 

Please choose yes even if it's occasionally. 

Are you nervous during dental treatment? 

If you are nervous during specific treatments only, please choose yes. Further explanation can be provided to your dentist. 

Are you pregnant? If yes, how many weeks? 

If you are unsure of the timeline, please provide an approximate answer. 

Do you have dental insurance? 

If yes, please list the company, plan and ID's, the subscriber of said plan and their birthday if different from yours. 

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If you have any questions or concerns throughout the form, we encourage you to contact 1 of our 6 dental clinics. A LifeSmiles Dental Corp rep will be happy to help you with the process. All of our contact information is listed here. 

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Thank you for choosing LifeSmiles Dental Corp!