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Appointment Request

Please note that appointments cannot be canceled through our online system. Please phone the office your appointment is booked at directly. Thank you for your consideration.

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Please enter an alternate contact number and preferred time to contact you.

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New Patient: Yes No

Preferred Contact time: Morning (8am to 12pm) Afternoon (12pm to 4pm) Evening (4pm to 7pm) ANY

* Location: Select your location of choice .... North East South West Downtown Specific Location If you prefer a specific location, please specify:
Preferred Appointment Day: Monday Tuesday Wednesday Thursday Friday Saturday ANY

Preferred Appointment time: Morning (8am to 12pm) Afternoon (12pm to 4pm) Evening (4pm to 8pm) ANY

The Appointment is For: (Select all that Apply) Yourself  Spouse  Child  Other  

Nature of Appointment: (Select all that Apply) Consultation  Checkup  Dental Cleaning  1 Hour Teeth Whitening   Emergency  Other

Please provide additional information: any questions or concerns, dental pain or symptoms, allergies, approx. date of last dental appt and xrays (if known). This information is kept confidential in accordance with federal and provincial privacy laws.

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Dental Plan and ID #:
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