Current Patient Form

Please complete the form below and a North Shores team member will contact you to schedule your next visit with us.

Please provide the following contact information:

First Name

Last Name

Title

Work Phone

Home Phone

E-mail
Contact me:
Best time to call me:

Preferred appointment day (Please refer to Office Hours before making a selection):

Monday          Thursday                     
Tuesday         Friday         
Wednesday       Saturday

Preferred appointment time (Please refer to Office Hours before making a selection):

morning                              
afternoon               
evening

Reason For Your Visit:

Routine Check-Up                              
Hygiene
Treatment Planned By Doctor (Please use comment box to specify)              
Specific Oral Health Complaint (Please use comment box to explain) 
Emergency (If you do not hear from us within 24 hrs, please go to your local hospital or call the DENTAL EMERGENCY HOTLINE AT 416-)

Comments

First Name
Last Name
Title
Work Phone
Home Phone
E-mail

Author information goes here.Copyright © 2005 North Shores Dental. All rights reserved. Revised: 04/09/05

Author information goes here.
Copyright © 2005 North Shores Dental. All rights reserved.
Revised: 04/09/05