Confirm Appointment

You can confirm your Pre-Scheduled Appointments by:

1.	Phone: (519) 756-8080
2.	Fax: (519) 756-0745
3.	On Line: Please provide the information below:
	* Confirm on line and win $100 gift certificate. Draw is made quarterly.

Please provide the following information:

*These fields are required

*First Name

*Last Name

Title

*Date of Birth yyyy/mm/dd

Address

City

Prov/State

Postal/Zip Code

Work Phone

*Home Phone

FAX

E-mail

Please confirm my Pre-Scheduled Appointment on:
	Month:	Date:	Time:
		:

Please use the space below to for additional information. Thank you!