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Patient Information



Date of Birth*

Which day(s) are you available on?
MondayTuesdayWednesdayThursdayFriday (AM)Saturday (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 Employees Group InsurancePublic of Government CDCP (Canadian Dental Care Plan with SunlifeStudents Insurance (ASEQ/ALUMO)Quebec Public Health Insurance (RAMQ) for Welfare Social AssistanceQuebec Public Health Insurance (RAMQ) for 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 CompanyInternetPassing byOther

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