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?
Yes
No
PERSONAL DETAILS
Your personal details. Please review them and make any necessary adjustments.
Title
Mr.
Mrs.
Ms.
Mstr.
Miss
Dr.
First Name
Last Name
Preferred Name
Gender
Female
Male
Non-Binary/Other
Unspecified/Prefer Not To Answer
Date of Birth
Address
Address 2
Prov./State
City
Postal /Zip Code
Home #
Work #
Ext.
Mobile #
Other #
Preferred Phone
Home
Work
Mobile
Other
Email
Contact Method
Email
Phone
Mail
Sms
Employer/School
Occupation
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
Emerg. Relation
Phone
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?
Yes
No
Are you experiencing any of the following symptoms (check any that apply)
Fever
Chills
Cough that's new or worsening
Shortness of breath
Sore throat
Difficulty swallowing
Hoarse voice
Runny nose
Stuffy or congested nose
Lost sense of taste or smell
Headache
Digestive issues
Fatigue
Falling down more than usual
Sluggishness/ lack of apetitite
Have you travelled outside of Canada in the last 14 days
Yes
No
Has someone you are in close contact with tested positive for COVID-19
Yes
No
Is anyone in your household currently awaiting test results for COVID-19?
Yes
No
