Parent/Guardian First Name

Parent/Guardian Last Name

Phone

Email Address

How many children would you like to schedule? How many children would you like to schedule? 12345+

Child Name(s)

Date of Birth(s)

Patient Address

What type of appointment would you like to schedule? Please select all that apply What type of appointment would you like to schedule? Please select all that apply Dental Cleaning/Checkup Treatment for Dental Cavities Referral from a General Dentist Frenectomy/Lip or Tongue Tie Dental Emergency Other

If other, please specify

Is your child currently covered by private insurance or a government funded dentistry program Is your child currently covered by private insurance or a government funded dentistry program Private insurance (ie. Manulife, Sunlife etc.) Healthy Smiles Ontario (HSO) Private Insurance & Healthy Smiles NIHB None Other

If other, please specify

Please list a few dates/times that work with you. We will try our best to accommodate your schedule

Please use this space to inform us of anything else we should know or other information that would be helpful