Appointment request

Full name * Phone * Email *

Your preferences:

Morning between 8am - 12pm
Afternoon 1pm- 5pm

Are you an existing patient or a new patient ?
New Patient Existing patient

Catégorie d’âge :

À quand remonte votre dernier examen-nettoyage :

Type of treatment requested:
Cleaning and dental exam Emergency

What is the intensity of your pain from 1 to 10? *10 being the worst of your life

How long have you had this pain ?

Have you taken any medication to relieve yourself

Implantology consultation

Do you have one or more missing teeth ?

Are you referred by a health professional ?

Is this a second opinion ?

Dental extraction

Are you referred by your dentist ?

Is it for the extraction of wisdom thoot ?

Êtes-vous en douleur ?

Cosmetic dentistry

What do you want to improve with your smile ?

Denturology

Are you partially or completely edentulous ?

Is it a new prosthesis or a replacement ?

When was the last time you had a prosthesis ?

Other

Specify :

We will contact you by phone as soon as possible to schedule an appointment according to your needs and availability.
Au plaisir,

WELCOME TO PATIENTS ELIGIBLE FOR THE
CANADIAN DENTAL CARE PLAN