Uptown Dental Hygiene - Appointment Request

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Call: 15199549092

15199549092

The first step towards a beautiful, healthy smile is to schedule an appointment. Please contact our office by phone @ 519-954-9092 or complete the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment.

Office Hours

Monday - Thursday 8:00 am to 5:00 pm

Friday 8:00 am to 4:00 pm

Saturday and evening appointments available apon request

Please do not use this form to cancel or change an existing appointment.

Items in bold are required.

Name:
Address:
City:
State/Province:
Zip/Postal:
Phone:
Email:

Are you a current patient?

YesNo

How did you hear about us?

Best time(s) to call?

MorningNoonAfternoonEvening

Which office location(s) would you prefer for your appointment?* Kitchener 1454 King St. East

Preferred day(s) of the week for an appointment?

Any DayMondayTuesdayWednesdayThursdayFriday

Preferred time(s) for an appointment?

Any TimeMorningNoonAfternoon

Please describe the nature of your appointment (e.g., consultation, check-up, etc.):

Do not fill this textbox.

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.

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