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Appointment Request

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* Name:
* Phone:
Alternate Phone:

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

* Email:
New Patient: Yes No

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

* 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.

Name of Dental Plan:
Dental Plan ID#:
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