Request an Appointment

Are you a new or existing/returning patient?
New patient Existing/Returning patient

New Patient Form

First Name *
Middle Name
Last Name*
Date of Birth*
Street Address*
City*
Postal Code
Province: ON QC
Home Phone*
Work Phone
Cell Phone
Email Address
Preferred method of contact phone email
How did you hear about us?*
If a referral, please enter the name here so we may thank him/her
Preferred Dentist
Main Reason for appointment*
Preferred time for appointment* morning
afternoon
evening
any time
Additional information about your appointment

Existing/Returning Patient Form

First Name *
Middle Name
Last Name*
Date of Birth*
Best Phone Number to reach you*
Email Address
If your address or phone numbers changed since your last visit, please enter your new information here:
Preferred method of contact phone email
Your Dentist*
Main Reason for appointment*
Preferred time for appointment* morning
afternoon
evening
any time
Additional information about your appointment