Online Booking - Emergency Visit
Thank you for completing this form. Once click submit at the bottom, you will be directed to a page where you can book and confirm your appointment.
Our office does not accept direct payment from insurance companies. Payment will be due at the time of the visit. We will file all insurance forms on your behalf and your insurance company will reimburse you.
Are you a new patient to our office?
Your personal details. Please review them and make any necessary adjustments.
Date of Birth
Postal /Zip Code
Are you available for short notice appointments? (Check if available)
How did you hear about us (Internet, Walk-In, Referred)? If Referred, please provide name of person/business.
Emerg. Contact First Name
Emerg. Contact Last Name
Name of parent
Please describe your dental emergency/urgent concern
The following questions apply to your child and anyone in your household. If you answer "YES" to any of the following questions please contact our practice at 905-303-6010 for further instructions.
Is anyone experiencing any of the following symptoms? Severe difficultly breathing, severe chest pain, feeling confused, losing consciousness?
Are you experiencing any of the following symptoms (check any that apply)
Cough that's new or worsening
Shortness of breath
Stuffy or congested nose
Lost sense of taste or smell
Falling down more than usual
Sluggishness/ lack of apetitite
Have you travelled outside of Canada in the last 14 days
Has someone you are in close contact with tested positive for COVID-19
Is anyone in your household currently awaiting test results for COVID-19?