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Patient Information

Which day(s) are you available on?
MondayTuesdayWednesdayThursdayFridaySaturday (AM)

What time slot(s) do you prefer?
No Preference (9AM - 5PM)Morning (9AM - 12PM)Afternoon (12PM - 5PM)Evening (Tuesday 5PM - 6:30PM)

Reason of your appointment?
Cleaning & Full EvaluationFull EvaluationConsultation (Evaluation & Treatment of Specific Problem)Emergency

Dental Insurance(s)
NoneWork Group InsuranceCanadian Dental Care Plan (CDCP)Students Insurance (ALUMO)/(Major)Quebec Public Health Insurance (RAMQ) for Welfare Social Assistance or Children under 10 years old

How did you hear about us? *I am Patient of your clinicBy one of your PatientsBy a Healthcare ProfessionalMy Insurance CompanyGoogleSocial MediaPassing byOther

(Optional) Please let us know of any details or concerns regarding your appointment request: