NAME *

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ARE YOU A NEW PATIENT

YES

NO

WHEN WOULD YOU LIKE AN APPOINTMENT *

IF YOU NEED AN IMMEDIATE RESPONSE CALL US DIRECT TO BOOK 905-856-7999

ASAP

WITHIN 24 TO 48 HOURS

WITHIN 3 TO 5 DAYS

IN THE NEXT 1 TO 2 WEEKS

IN THE NEXT MONTH

IN THE NEXT 2-3 MONTHS

I'M NOT SURE YET

ARE YOU COVERED UNDER EITHER OF THE BELOW PROGRAMS? *

REFUGEE DENTAL CARE (IFHP)

CANADIAN DENTAL CARE PLAN

NEITHER