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Your SW Calgary Family & General Dentist
Phone:(403) 259-3401

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New Patient, Dental & Medical History Forms

    Welcome to Ultima Dental Wellness!
    Please kindly complete our Confidential Patient Information, Dental & Medical History Forms.

    PERSONAL INFORMATION


    INSURANCE INFORMATION

    Primary Insurance Information

    Secondary Insurance Information

    DENTAL HISTORY

    PLEASE CHECK TO ANSWER YES TO ANY OF THE FOLLOWING QUESTIONS:

    PERSONAL HISTORY

    CHECK IF YES

    Yes
    Yes
    Yes
    Yes
    GUM AND BONE

    CHECK IF YES

    Yes
    Yes
    Yes
    Yes
    TOOTH STRUCTURE

    CHECK IF YES

    Yes
    Yes
    Yes
    Yes
    Yes
    BITE AND JAW JOINT

    CHECK IF YES

    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    SMILE CHARACTERISTICS

    CHECK IF YES

    Yes
    Yes
    Yes
    Yes

    MEDICAL HISTORY


    DO YOU HAVE or HAVE YOU EVER HAD:

    Yes
    Yes


    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes

    Yes
    Yes

    Yes
    Yes

    ARE YOU:

    Yes

    Yes
    Yes
    Yes

    Yes
    Yes
    Yes

    Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)

    Drug & Purpose 1

    Drug & Purpose 2

    Drug & Purpose 3

    Drug & Purpose 4

    PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

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    The Ultima Dental Wellness team is committed to working together to ensure that every patient who visits us has an experience that exceeds their expectations, each and every time!

    Find us on best in Calgary | Ultima Dental Wellness | Best In Calgary Dentists

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    Practice Hours

    Our
    Practice Hours

    Monday: 8:00 am to 3:00 pm

    Tuesday: 9:00 am to 6:00 pm

    Wednesday: 9:00 am to 6:00 pm

    Thursday: 7:00 am to 4:00 pm

    Friday: 8:00 am to 4:00 pm

    Saturday: By Appointment Only

    Sundays: Closed

    Statutory Holidays: Closed

    Contact Us

    #202, 506 – 71 Avenue SW
    Calgary, Alberta
    T2V 4V4
    (403) 259-3401

    Disclaimer

    The dentists at Ultima Dental Wellness are all General Dentists. As general dentists, they provide cosmetic dental procedures such as porcelain veneers, dental crowns, dental braces, and teeth whitening as part of their General Dentistry license. Cosmetic Dentistry & Family Dentistry are not recognized dental specialties by the Alberta Dental Association & College of Dental Surgeons of Alberta (CDSA). As SW Calgary Dentists, they provide General Dental procedures for all ages within the family.
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