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Schedule appointment
Appointment request
Please fill out our appointment request form and submit. We will contact you shortly to confirm the date and time of your appointment.
Patient information
Patient name
*
First
Last
Date of birth
*
Date Format: MM slash DD slash YYYY
Parent name (if applicable)
First
Last
Additional parent name (if applicable)
First
Last
Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Telephone (daytime)
*
Telephone (alternative)
Email
*
Appointment details
Provider
*
Dr. Carolyne Thain, Orthodontist
Dr. Nawar Touchan, Periodontist
Tom Szarski, Denturist
Reason for appointment?
Schedule an initial orthodontic consultation
Reschedule an appointment (minimum 48 hours in advance)
Which day is preferable? (check all applicable boxes)
Monday
Tuesday
Thursday
Are you currently a patient with us?
Yes
No
Who referred you?
My dentist
My friend
This website
Internet search
Other
Additional information