Contact Us
R e q u e s t   a n   A p p o i n t m e n t
 
Please use this convenient form to request an appointment. We will make every effort to get back to you as soon as possible to schedule your visit. [For emergencies please call (613) 686-3866
 
  Full Name of Patient:    
     
       
  Email:    
     
       
  Phone number where we can reach you:    
     
       
  I am an:    
  Existing patient New patient    
       
  Preferred days of the week that you can see us:    
  Monday    
  Tuesday Preferred time of day:    
  Wednesday Morning    
  Thursday Mid-day    
  Friday Afternoon    
       
  What is the purpose of your visit:    
     
       
  Security Code:  

Type the characters you see in the picture below. Letters are not case sensitive.
   
       
 
   
       
   
       
Site By Dr. Alex Wakter & WebMarketingForDentists   |   Disclaimer.