Southview Dental | Request an Appointment

Please use this form to request a new appointment only. If you wish to cancel or modify an existing appointment, please call our office at 905-876-4701.

Also, please contact us by telephone or see us in person if your request is of a confidential or private nature.

All fields must be completed in order to submit the form.

Name
Address
City
Province
Postal Code
Email
Home Phone
Work Phone
Cell Phone

How would you like us to contact you?
Home Phone Work Phone Cell Phone Email

What is your patient status?	New Patient Existing Patient
What is the best time to contact you?
Morning Noon Afternoon Evening Any time

What day do you prefer for your appointment?

Mon Tues Wed Thurs Fri Any day

What is your preferred appointment time?

Morning Noon Afternoon Evening Any time

Please describe the nature of your appointment: (eg: cleaning, cosmetic)

We will contact you two weeks prior to your appointment and again 24 hours prior to your appointment to confirm.