Facebook Twitter Google Yelp

New Patients Are Welcome!

REQUEST AN APPOINTMENT
(587) 801-7094
google-1.png
“People Love Us On Google”
290+ Google reviews

New Patient Form Additional Child

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

  • MM slash DD slash YYYY

  • Patient Medical History

  • Patient Dental History

  • Upload a Photo

  • Max. file size: 50 MB.
  • 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 South Airdrie Smiles 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.
logo-white
130 Sierra Springs Dr SE Unit 3001, Airdrie, AB T4B 3G6, Canada. | Phone: (587) 801-7094
Facebook Twitter Google Yelp
© 2021 South Airdrie Smiles | All Rights Reserved.
MENU
Request An Appointment