Are you a new or existing/returning patient? New patient Existing/Returning patient New Patient Form First Name * Middle Name Last Name* Date of Birth* Day 01020304050607080910111213141516171819202122232425262728293031 Month JanFebMarAprMayJunJulAugSepOctNovDec Year 2011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 Street Address* City* Postal Code Province: ON QC Home Phone* Work Phone Cell Phone Email Address Preferred method of contact phone email How did you hear about us?* - select - Word of Mouth Referred by somebody Internet Search Mall Sign Print Ad Other If a referral, please enter the name here so we may thank him/her Preferred Dentist Dr. George Barlas Dr. Pierre Maranger Dr. Marc Beaupré Dr. John Kokkinakis No preference Main Reason for appointment* - select - Regular Check up & Cleaning Tooth Pain Gums Inflammation Crown / Bridges / Cerec Invisalign Replacing Missing Teeth Braces Teeth Whitening Others Preferred time for appointment* morning afternoon evening any time Additional information about your appointment Existing/Returning Patient Form First Name * Middle Name Last Name* Date of Birth* Day 01020304050607080910111213141516171819202122232425262728293031 Month JanFebMarAprMayJunJulAugSepOctNovDec Year 2011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 Best Phone Number to reach you* Email Address If your address or phone numbers changed since your last visit, please enter your new information here: Preferred method of contact phone email Your Dentist* - select - Dr. George Barlas Dr. Pierre Maranger Dr. Marc Beaupré Dr. John Kokkinakis Forgot the name Main Reason for appointment* - select - Regular Check up & Cleaning Tooth Pain Gums Inflammation Crown / Bridges / Cerec Invisalign Replacing Missing Teeth Braces Teeth Whitening Others Preferred time for appointment* morning afternoon evening any time Additional information about your appointment
