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Preferred Contact Method Preferred Contact Method Phone Email

Are you requesting an appointment? Are you requesting an appointment? Yes No

Is it a routine check-up? Is it a routine check-up? Yes No

Do you have a specific concern? Do you have a specific concern? Yes No

Requested Dentist (if applicable) Requested Dentist (if applicable)Dr. Lily SammakDr. Graeme LackieDr. Sheheryar CheemaNot Applicable

Do you have a preferred day and time? Do you have a preferred day and time? Yes No

Choose A Date and Time- Monday to Friday AM or PM

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