New Patient Information Form

Step 1 of 6 - Personal Information

Name*
First Name Last Name
Email*
Home Phone*
Cell Phone*
Date of Birth*
Address*
Street Address City Province Postal Code
Gender*
- Male
- Female
- Other
Emergency Contact*
Emergency Contact Number*
How did you hear about us?*
- Google Ads
- Google Maps/Google Search
- Billboard Signs
- I Live Nearby
- Referred By Friend
- Social (Facebook, Instagram & Youtube)
Who referred you to our office?*

We would like to thank the person that invited you to our office.

Employer*
Occupation*
Do you have Dental Insurance?*
- Yes
- No
Name of Dental Insurance Subscriber*
First Name Last Name
Date of Birth of Subscriber*
Name of Insurance Provider*
Group/Plan Number*
Certificate/ID Number*
Do you have a second Insurance Provider?*
- Yes
- No
Name of Dental Insurance Subscriber*
First Name Last Name
Date of Birth of Subscriber*
Name of Insurance Provider*
Group/Plan Number*
Certificate/ID Number*

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Beacon Smiles Dental

Beacon Smiles Dental is a family and cosmetic dental clinic. We provide orthodontic services such as Invisalign, Braces, and Myobrace. We are located near Sarcee Trail NW in Beacon Hills. New patients welcome, evening and weekend appointments.

Serving the communities of:

Sherwood
Nolan Hill
NW Calgary
Sage Hill
Citadel

Links List

Hours Of Operation

Monday: 12:00 p.m. to 7:30 p.m.
Tuesday: 7:30 a.m. to 7:30 p.m.
Wednesday: 7:30 a.m. to 7:30 p.m.
Thursday: 9:00 a.m. to 4:30 p.m.
Friday: 8:00 a.m. to 3:30 p.m.
Saturday: 9:00 a.m. to 3:30 p.m.
Sunday: Closed