test required field CF7

    Please select a doctor*
    Dr. Nach DanielDr. Eric St-GermainDr. Karim Al-KhatibAny doctor
    Patient Name*
    		 Today's date*
    Date of Birth*
    		 Patient Email
    Is this for a child?
    NoYes
    Parent/Guardian
    Telephone Number*
    		 Address
    Please select one

    Dental InsuranceIndian AffairsSocial AssistanceNot applicable
    Type of treatment :

    ExtractionExposureTMJApical SurgeryPathologyImplantologyJaw SurgeryPreprosthetic Surgery
    Adult Teeth Charting

    D 1817161514131211 2122232425262728 G
      4847464544434241 3132333435363738  
    Youth Teeth Charting:

    D 5554535251 6162636465 G
      8584838281 7172737475  
    X-Ray Request*

    X-Ray 1:
    Date*

    X-Ray 2:
    Date*

    X-Ray 3:
    Date*

    Max. 15MB / file, allowable formats JPG or PNG, Dates: day month year

    Referring dentist* :
    Office email* :
    Remarks
    If you need a copy of this form for your records, click the print button below BEFORE sending the form

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    Basic GPG test below