Ready to join our long list of happy patients?

We’ve made our new patient booking process as simple as can be, just fill out the questions below and press submit when you’re done.

Looking to book the entire family? No problem, at the end of the form you’ll have the option to complete additional (and shorter!) forms for the other members of your family.

Name*
First Last
Date of Birth*
DD-MM-YYYY
Consent for Release of X-Rays and Transfer of Records*
I, {Name (First):3.3} {Name (Last):3.6} (D.O.B.: {Date of Birth:12}), hereby authorize the release of my dental records to:

Chapel Hill Dental
3400 ch. Innes Rd., Orléans, ON K1W 0G1
Tel.: 613.424.4241 Fax: 613.424.8887
Email: smile@chapelhilldental.ca

Please forward all recent x-rays by email to Chapel Hill Dental at your earliest opportunity, together with the following information to assist them going forward:

Date of last COE
Date of last Recall Exam
Date of last Bite Wings
Date of last Panoramic Image

Thank you for your cooperation.
I consent to the above
Signature (Patient/Guardian)

Quick contact

3400 Innes Rd., Orléans, Ontario K1W 0G1

Tel.: 613-424-4241
Fax: 613-424-8887
Email: smile@chapelhilldental.ca