Cosmetic Treatment and General Dentistry

The First Step. Meeting you.

By providing detailed information about yourself and your medical history, you will save time when you visit our office. Your information is secure and will be kept strictly confidential.

Personal Information

* First Name:

* Last Name:

* Address:

* Address 2:

* City:

* Province:

Postal Code:

* Phone Number ex. (403) 543-4600:

Daytime Phone Number:

* Email Address:

* Date of Birth:

Your Dental Needs

Do you have any areas of concern?

Tell us in your opinion, what you think the present state of health your mouth is in:

Excellent

Very Good

Average

Poor

Ugly

How healthy do you want us to get your mouth?:

Don't really care

Average

The best it can be

Tell us about your good dental experiences, what do you look for in a practice, what has pleased you in the past?

Tell us about any bad dental experiences, what do you dislike in a dental practice, have you had any past negative experiences?

What caused you to leave your last dental office?

If there was one thing you could change about your smile, what would it be?

What would it take for you to trust us to be your dentist?

How did you find out about Aesthetic Dental Studio?

What do you already know about our office and what are your expectations?

Has fear ever been an issue for you in a dental office?

Yes

Has time ever been a factor in getting your dental work done?

Yes

Has the cost of dental treatment been a concern for you?

Yes

What can we do to help you with this?

We have the unique ability to look at your mouth from 3 different perspectives. What combination of these would you like us to use for you? (please check all that apply)

As a general dentist
As a cosmetic dentist
As a functional (TMD/TMJ Relief) dentist

At what point would you like us to initiate treatment? (Please check all that apply)

When my tooth hurts or breaks
When something is worsening
When something isn't ideal

What quality of dentistry do you want us to recommend?

Just patch it

Average

Ideal/the best

Is there any additional information you would like us to know?

Health and Dental History

* Have you been under the care of a medical doctor during the past two years?

Yes No

If so, for what?

* Physician's Name

* Physician's Phone Number ex. (403) 543-4600:

* Are you taking any medication now, including regular dosages of aspirin?

Yes No

If yes, please list name and dosage

* Are you aware of having an allergic reaction to any medication or substance?

Yes No

If yes, please list

* Indicate which of the following you have had, or have at present.

(Please check Yes or No to each)
* Have you had braces?

Yes No

* Do you see a chiropractor?

Yes No

* Does floss shred when you use it?

Yes No

* Does food pack or catch between your teeth?

Yes No

* Do you smoke or chew tobacco?

Yes No

* Do your gums bleed?

Yes No

* Does your breath concern you?

Yes No

* Are you aware of any snoring or breathing problems when you sleep?

Yes No

* Do you commonly feel tired or fatigued?

Yes No

Do you have or have you had any disease, condition or problem not listed?

Are you active in any sports?

Yes No

Women:

(Please check all that apply)
Are you:

Pregnant? Nursing? Taking birth control pills?

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider who may release such information to you. I will notify the doctor of any change in my health or medication.

* I Agree to the above

Remember to fill out and submit this form at least two days prior to your visit.

Our office is conveniently located on the second level in the professional office section of the Dalhousie Station Shopping Complex. We are in the NE corner of the mall, approximately 30 meters north of the front entrance of the Chapters book store.

For those patients approaching from Crowchild Northbound

Head on Crowchild Northbound past the University and past the Shaganappi intersection. Get in the right lane. Your next turn off will be the 53rd St exit. Take your first right prior to the 53rd St. exit and this will take you to a left turn into the mall. Take your first right, go past the front of Chapter's and park to your left or right. Our office is on the 2nd level off to your right as you go past Chapter's. Welcome!

For those patient approaching from Crowchild Southbound

Head on Crowchild past the NoseHill intersection and again past the Sarcee intersection. Get in your right hand lane and take the 53rd St. exit. Once you are up the ramp take a left and this will put you on 53rd St. North. Get in your right hand lane and take the first exit to the right and enter into the mall parking lot. We are located dead ahead at the far end of the parking lot, 2nd level, to the left of Chapter's. Welcome!

"Our dentists are committed to you and your smile."

Dr. Gordon Chee

Calgary General Dentist Disclaimer: Aesthetic Dental Studio for Cosmetic Dentistry in Calgary has provided this website about cosmetic dentistry procedures, including Porcelain Veneers, Endodontics, Tooth Crowns, Dental Implants and Teeth Whitening for informational purposes only. It is not intended to provide medical advice nor does the use of this site create a doctor-patient relationship. Aesthetic Dental Studio serves cosmetic dentistry clients in Calgary, Alberta, Northwest Calgary and Airdrie.

403.543.4600 • Contact Us

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