Schedule appointment - Imagine Orthodontics

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.

"*" indicates required fields

Patient name*

First Last

Date of birth*

Parent name (if applicable)

First Last

Additional parent name (if applicable)

First Last

Address*

Street Address Address Line 2 City Province Postal Code

Telephone (daytime)*

Telephone (alternative)

Email*

Provider*

Reason for appointment?

Which day is preferable? (check all applicable boxes)

Monday

Tuesday

Thursday

Are you currently a patient with us?

Who referred you?

Additional information