This field is for validation purposes and should be left unchanged.
Name of Person on the original form*(Required)
Name of Patient*(Required)
MM slash DD slash YYYY
Select a Choice*(Required)
University/College Student*(Required)
How would you prefer your appointment reminders?*(Required)
Do you have insurance?*(Required)
Do you have secondary insurance?*(Required)
Are you dissatisfied with the appearance of your smile?*(Required)
Do you have? (please check the following that apply)*(Required)

Patient Medical History

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