New Patients are Welcome! Extended hours! online scheduling

South Airdrie Smiles

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New Patients: (587) 805-3094
Existing Patients: (403) 980-6363

Dear Patients,

During these uncertain times you can depend on South Airdrie Smiles to continue serving our community.

We are keeping our doors open for dental emergencies and your immediate treatment needs. Whether you are a current patient, or are looking for a dental clinic that is open, we are here for you.

Please give us a call if you need to see a dentist right away.

Yours in Health,

The Team at South Airdrie Smiles

New Patients: (587) 805-3094 | Existing Patients: (403) 980-0404

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»New Patient Form Child»

New Patient Form Child

New Patient Form Additional Child

Patient Information (Confidential). All fields are mandatory, please enter n/a if they do not apply.

Name*
First Name Last Name
Parent or Guardian's Name*
First Name Last Name
Birth Date*
Parent's Home Phone
Parent's Work Phone
Email*
Select a Choice*
- Male
- Female
Is there anyone else in your household that is a patient here?*
- Yes
- No
Address/ City /Prov /Postal code*
Street Address City State / Province / Region ZIP / Postal Code
Can you give us their name please?*
Person to Contact in Case of Emergency*
Relationship to Patient*
Phone Number*
How Did You Hear About Us?*
Please tell us the name of the family or friend who referred you.
How would you prefer your appointment reminders?*
- Via Mail
- Phone Call
- Text Message
Do you have insurance that covers this child?*
- YES
- NO
Do you have secondary insurance?*
- YES
- NO
Patient Medical History
Physician*
Physician's Office Phone
Is the child currently under any medical treatment?*
- YES
- NO
Has the child been admitted to a hospital or needed emergency care during the past two years?*
- YES
- NO
Is the child currently taking any medications, including over the counter medications?*
- YES
- NO
Has the child ever had any complications following dental treatment?*
- YES
- NO
Do you have or have had any of the following? Please check all that apply.*
- AIDS/HIV
- Anemia
- Arthritis
- Artificial Joints
- Asthma
- Blood Disease
- Cancer
- Diabetes
- Dizzieness
- Epilepsy
- Excessive Bleeding
- Fainting
- Glaucoma
- Head Injuries
- Heart Disease
- Heart Murmur
- Hepatitis
- High Blood Pressure
- Kidney Disease
- Liver Disease
- Mental Disorders
- Pacemaker
- Radiation Therapy
- Respiratory Problems
- Rheumatic Fever
- Rheumatism
- Sinus Problems
- Stomach Problems
- Strock
- Tuberculosis
- Tumors
- Venereal Disease
- Smoker
- None
Do you have any allergies to medications?*
- YES
- NO
Patient Dental History
Check All That Apply*
- Gums bleed while you brush
- Your teeth are sensitive to hot or cold liquid/foods
- You feel pain in any of your teeth
- Have any sores/lumps in your mouth
- Have any head, neck or jaw injuries
- Ever experience any clicking or pain in the TMJ area, difficulty opening or closing
- Have frequent headaches
- You clench or grind your teeth
- You bite your lips or cheeks frequently
- Had any difficult extractions or prolonged bleeding from it in the past
- Had any orthodontic treatments
- You wear dentures or partials
- None
Upload a Photo
We need a photo of of each patient for our records. If you have a clean headshot of the patient above please upload it here. Otherwise we can take a photo when they arrive.
I agree to pay value of said services,which shall be as billed unless objected to by me, in writing, within the time for payment thereof. I agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I understand my personal information disclosed is protected by the Privacy Act. I agree that Beacon Smiles Dental can electronically file dental claims on my behalf. In compliance with Canadian Anti-Spam Laws, you understand that by clicking submit, you give us permission to send you information on products and services and information such as news and events.
*
- I have read the above conditions of treatment and payment and agree to their content.

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CONTACT

South Airdrie Smiles

New Patients: (587) 805-3094
Existing Patients: (403) 980-6363

Address: 130 Sierra Springs Drive SE,
Unit 3001 Airdrie, AB T4B 3G6

(by the The Canadian Brewhouse and Mr. Mikes)

OFFICE HOURS

Monday: 11:00 AM – 7:00 PM
Tuesday: 9:00 AM – 5:00 PM
Wednesday: 8:00 AM – 4:00 PM
Thursday: 8:00 AM – 4:00 PM
Friday: 8:00 AM – 4:00 PM
Saturday : 9:00 AM – 3:00PM
Sunday : Closed

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