Appointment Request Form Please fill in the form below to setup an appointment.Reason for AppointmentPlease provide a reason for your appointment. Details are stored securely and not sent by email.Preferred Date & Times*Please let us know when you would prefer to have your appointment. Our hours are listed on our location page.Patient Type*New patientReturning patientPlease let us know if you are a new or existing patient.Name* First Last Phone*Email* Best Time to be Reached for Confirmation* : HH MM AM PM CommentsCanadian Anti-Spam LegislationAs per the Canadian Anti-Spam Legislation, I am providing my Express Consent to communicate electronically. I understand that my consent may be withdrawn at any time by emailing firstname.lastname@example.orgPlease confirm your consent to receive electronic communications from us.* Yes, I do give consent No, I do not give consent PhoneThis field is for validation purposes and should be left unchanged.