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Patient Information

Your Availability (you can choose more than one)
MondayTuesdayWednesdayThursday

Your Preference (you can choose more than one)
Morning (9AM - 12 noon)Afternoon (12 noon - 4PM)

Reason of the visit? (you can check more than one)
Cleaning & Full EvaluationFull EvaluationSpecific Region Consultation (1 to 2 teeth in a particular region)Emergency (pain, swelling, broken tooth, fallen filling, concern, ...)FillingsGum TreatmentRoot CanalCrownTooth ExtractionEstheticWhiteningReplacing Missing TeethDentures

Dental Insurance (choose one)
NoneJob InsuranceStudent Care Insurance (ASEQ)Government (CDCP)

How did you hear about us? *Already patient of the clinicReferred by one of your patientsMy insurance company listSearch engine (Google, Google maps, etc)Passing byOther

Additional information if desired