Patient Forms - Southport Dental Care

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Southport Dental Care

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117 Southport Atrium 10333 Southport Road S.W, Calgary, AB, Canada, T2W 3X6

(403) 255-3202

info@southportdental.ca

Monday : 7:00am – 5:00pm

Tuesday : 7:30am – 6:00pm

Wednesday : 7:00am – 4:00pm

Thursday : 8:30am – 6:00pm

Friday : 8:00am – 2:00pm

Saturday : Closed

Sunday : Closed

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Services

General Dentistry

composite-fillings

Composite Fillings

dental-bonding

Dental Bonding

dental-bonding

Dental Bridges

Dental Crowns

Dental Crowns

Dental Extractions

Dental Extractions

Dental Implants

Dental Implants

Dentures

Dentures

Root Canal

Root Canal

Same-Day Crowns

Same-Day Crowns

Teeth Cleanings

Teeth Cleanings

Cosmetic Dentistry

Dental Veneers

Dental Veneers

Invisalign

Invisalign

Teeth Whitening

Teeth Whitening

Children’s Dentistry

Child’s First Appointment

Child’s First Appointment

Fluoride Treatment

Fluoride Treatment

Pediatric Treatment & Education

Pediatric Treatment & Education

Teeth Cleaning for Kids

Teeth Cleaning for Kids

Additional Services

Oral Cancer Screening

Oral Cancer Screening

Sedation

Sedation

Sleep Apnea Treatment

Sleep Apnea Treatment

Sports Guards

Sports Guards

TMJ Therapy

TMJ Therapy

Tooth Sensitivity Treatment

Tooth Sensitivity Treatment

Wisdom Teeth Extraction

Wisdom Teeth Extraction

Dental Emergencies

Request an Appointment

1. Are you an existing patient with our practice? *

Yes
No

2. What is the reason you need a dental visit?

Let us know what you need so we can make sure you get the best care - even if it's just a checkup! *

Checkup & Cleaning
Second Opinion
Third Opinion

3. Do you have a preferred time to see the dentist? *

Early (Before 9am)
Morning (9am - 12pm)
Noon (12pm - 2pm)
Afternoon (2pm - 5pm)
Evening (After 5pm)

4. How soon do you want to visit the dentist? *

As soon as possible
Within 1 week
Within 2 weeks
In more than 2 weeks

5. Are you experiencing any kind of pain? *

Yes
No

6. Describe the situation that the doctor should be aware of?

Is it a sharp pain or dull pain? When did it start? Are you taking any medication? *

7. What is your name? *

8. What is the best phone number to reach you at? *

9. What is your email address? *

10. When would be a good time for our staff to reach you and confirm the appointment?

Should we contact you via phone or email? Would it be better to call in the morning or afternoon? *

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