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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:
5554535251
6162636465
8584838281
7172737475
X-Ray Request* —Please choose an option—X-Ray(s) AttachedX-Ray EmailedPlease Take X-Ray
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* :
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