New Patient

Welcome to Ultima Dental Wellness! Please kindly complete your Confidential Patient Information form.

PERSONAL INFORMATION

Name:

Preferred Name:

Address:

City:

Postal:

Cell Phone:

Home Phone:

Bus Phone:

Ext

E-Mail Address:

Family Physician:

Telephone:

Emergency Contact Name:

Emergency Contact Number:

Occupation:

Whom may we thank for your referral to our office?

Other:

INSURANCE INFORMATION

Primary Insurance Information

Name of Insured:

DOB:

Employer:

Name of Insurance Co:

Policy#

ID#

Div#

Secondary Insurance Information

Name of Insured:

DOB:

Employer:

Name of Insurance Co:

Policy#

ID#

Div#

Print Patient Name:

Date:

Signature:

92278

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!

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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: 9:30 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 info@ultimadentalwellness.ca

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.