This field is for validation purposes and should be left unchanged.
Name*(Required)
Parent or Guardian's Name*(Required)
MM slash DD slash YYYY
Select a Choice*(Required)
Is there anyone else in your household that is a patient here?*(Required)
How would you prefer your appointment reminders?*(Required)
Do you have insurance that covers this child?*(Required)
Do you have secondary insurance?*(Required)

Patient Medical History

Is the child currently under any medical treatment?*(Required)
Has the child been admitted to a hospital or needed emergency care during the past two years?*(Required)
Is the child currently taking any medications, including over the counter medications?*(Required)
Has the child ever had any complications following dental treatment?*(Required)
Do you have or have had any of the following? Please check all that apply.*(Required)
Do you have any allergies to medications?*(Required)

Patient Dental History

Check All That Apply*(Required)

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.

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.

New Patients & Emergency Appointments Welcome!

Grande Dentistry is accepting new patients of all ages. Call today to schedule an appointment. We offer all dental services for all ages. Our goal is to create a comfortable experience for you and your family.
403-840-0077
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