Request an Appointment at Dentistry @ Queenston

We just need to ask you a few quick questions.

⏱️Takes 3 minutes

Are you an existing patient with our practice? *

Yes

How did you find out about our practice? *

Internet

Flyer / Mailer

Poster / Sign / Billboard

Referral / Word-of-Mouth

Other

How long has it been since you last visited the dentist?

<1 Year

1 - 2 Years

2+ Years

I've Never Visited

What is the reason you need a dental visit? *

Checkup & Cleaning

Specific Treatment

Urgent Issue

Let us know what you need so we can make sure you get the best care - even if it's just a checkup!

What dental service would you like to discuss on your visit? *

Composite Fillings

Dental Bonding

Dental Bridges

Dental Extractions

Dental Crowns

Dental Implants

Dentures

Root Canal

Dental Veneers

Invasalign

Teeth Whitening

Child's First Appointment

Sealants and Fluoride Treatment

Orthodontics for Teens

Pediatric Treatment & Education

Oral Cancer Screening

Sedation

Tooth Sensitivity Treatment

Sports Guards

Other

Please describe the urgent issue you are experiencing and would like the doctor to know about.

Are you experiencing pain? Do you have a cracked or broken tooth?

Do you have a preferred time to see the dentist? *

Morning (9am-12pm)

Noon (12pm-2pm)

Afternoon (2pm-5pm)

Evening (After 5pm)

How soon do you want to visit the dentist? *

As soon as possible

Within 1 week

Within 2 weeks

In more than 2 weeks

Do you have dental insurance?

Yes

Who provides your dental insurance?

Manulife Financial

Sun Life Financial

Great West Life

Green Shield Canada

Blue Cross

Desjardins

CDCP

Healthy Smiles

Other

Are you experiencing any kind of pain?

Yes

What is your name? *

What is the best phone number to reach you at? *

What is your email address? *

When would be a good time for our staff to reach you and confirm the appointment?

Should we contact you via phone or email? Would it be better to call in the morning or afternoon?

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Thank you for your appointment request. Our team will contact you shortly.