Our Hours

Monday to Friday: Saturday’s, Sunday’s & Statutory Holidays:

Our Location

South Calgary Periodontal Group Suite #201, 747 Lake Bonavista Drive SE Calgary, Alberta, T2J 0N2

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Patient Registration


Download PDF Patient Registration Form

Please complete the following information as best as possible and click on submit at the end. Alternatively, if you do not wish to use the online form submission. Please download the PDF form from the link to the right. If you have any questions about this form, do not hesitate to contact us directly at (403) 278-5446 before submitting the form.

Please fill out the information below as completely as possible.

IMPORTANT: When you click submit, you will receive a successful confirmation message. If you do not see the confirmation message, you will need to check through the form and complete any missing information. A confirmation e-mail will be sent to you confirming the successful submission to the South Calgary Periodontal Team.

    Patient Information

    * indicates required

    Insurance Information
    Do you have dental insurance? YesNo

    Dual Plan

    Health Information

    Periodontal disease may be caused by a combination of several factors and the following questions are designed to help us identify them. The success of therapy is dependent upon this. Therefore, although some of the following questions may seem unrelated to your periodontal condition, they are all associated with proper management of your oral health.

    All information provided is kept strictly confidential.

    (example: aspirin, tranquilisers, steroids, etc.)*

    Has your general health changed in the past year?Have you ever had any serious illness or major operations?Have you had abnormal bleeding associated with previous tooth extraction, surgery, or trauma?Do you have any allergies? (food, dust, drugs, fur, latex, etc.)?

    Dental anaesthetics (novocaine, etc.)AspirinPenicillin or other antibioticsCodeineBarbituates (sleeping pills)Other drugs

    Dental History

    For Women Only

    Consent (required)

    *Please ensure consent acceptance is checked. Form will not submit otherwise.

    Form Submission sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information. Please review our privacy policy and website terms of use prior to submitting your referral request.

    At South Calgary Periodontal Group, we are always welcoming new patients.
    Call us at (403) 278-5446 to book your consultation appointment today!