Appointment Request Form

Appointment Request

We understand your need to receive treatment in a practice that makes you feel comfortable, safe, and welcome. Please feel free to schedule a new patient consultation appointment by filling out the form below, or stop by for a complete tour of our practice. Please, note that you do not need a referral from your general dentist in order to see an orthodontic specialist.

You will get to meet our team, walk through our office and treatment areas, and learn more about the treatments we provide.

**For current or previous patients we ask you please call us at 613-225-5511**

Name*
Email*
Phone*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Patient Date of Birth*
MM slash DD slash YYYY
Current Dentist Name*
Current Dental Clinic Name
Cell Phone*
Home/Work/Other Phone
Parent/Guardian Name (If Under 18)*