Your SW Calgary Family & General Dentist

Fill out the forms below and press the submit button after completing each form.
Please fill the form in its entirety.

Please fill out one form per patient. This will help us speed-up the initial check-in process.

    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.


      OFFICE POLICIES

      Ultima Dental Wellness is hereby authorized to maintain the “Patient(s)” financial information in its records in order to make arrangements for payment of dental services from the Patient’s benefits provider(s). Ultima Dental accepts the assignment (direct billing) of dental benefits for the Patient’s convenience. If you request direct billing to your dental plan, a valid credit card is required to be left on file. This card will also be charged for any unforeseen balance not collected at the time of the visit and not paid by your dental benefits plan. Ultima Dental agrees not to disclose credit card information to third parties or to use credit card information unless authorized by the Patient to do so. The patient hereby agrees that amounts owing after payment of insurance benefits will be charged to the Patient’s credit card unless alternative arrangements are made and agreed to by both Parties.

      With regard to dental health benefit plans, it should be realized that the plan is between the benefits company and the employee (i.e. patient) and as such the details of coverage are unknown to Ultima Dental. Ultima Dental will attempt to estimate the cost of the proposed treatment as accurately as possible. However, in the event of a discrepancy between the estimated cost and the actual cost of the treatment, the difference will be the responsibility of the account holder.

      CANCELLATION POLICY

      If it becomes necessary to cancel an appointment, I understand that 48 hours notice is required for cancellation of that appointment. There will be a $75 per hour fee for missed or no-show appointments which will immediately be charged to my credit card on file without further notice.

        X-RAY RELEASE FORM

        To release health care information of the patient name above, to:

        Ultima Dental Wellness

        Suite 202, 506 - 71 Avenue SW

        Calgary, AB, T2V-4V4

        Phone: (403) 259-3401 | Fax: (403) 253-9791

        Email: info@ultimadentalwellness.ca

        This request and authorization apply to:

        • Copy of complete dental chart including periodontal measurements
        • Copy of dental x-rays (including Panoramic or FMS)

        I understand that my express consent is required to release any healthcare information relating to testing, diagnosis and treatment.

        Please forward all copies at your earliest convenience. I thank you in advance for your cooperation.