Make An Appointment
If you are a new or existing patient and wish to request an appoinment, you can fill out our on-line form. Simply fill out the form below as much as possible, then click "Submit" at the bottom of the page, and we will get back to you within 24 hours. Of course, you can always give us a call at 613-825-9393, and one of our receptionists will be happy to assist you.


First Name:
Last Name:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
   
Reason for Appointment:
Preferred Time
New Patient? Yes      No

Have you been seen by a previous dentist? Yes      No

If so, have you had X-ray in the last two years? Yes      No

How did you hear about us?

Additional Information:

If a referral, please enter the name here so we may thank him/her.
 

*Please remember to avoid any charges, we require 48 hours notice for cancellation*

 

 

 

 

 

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