Patient Application Form

 
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To apply to become a patient please fill out the form below and submit it. Wait times vary from 3 – 6 months and a patient coordinator will contact you to book a screening appointment at which time it will be determined if you are a suitable patient for our clinic.

Please be advised that patients with limited treatment needs (i.e. less than 4 fillings, no need for crowns, root canal treatment, denture, etc.) are not likely to be accepted for treatment in our clinic.

Section A: Please enter answers below
Last Name *
First Name *
Sex *
Date of Birth *
Address *
City *
Province *
Postal Code *
Home telephone
Work telephone
Cell phone *
Best time to contact
Best way to contact