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604-299-1661

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  • 604-299-1661
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Book an Appointment

Book an
Appointment

Appointment

840-2025 Willingdon Ave Burnaby BC V5C 0J3

Complimentary underground parking available. Please follow Office visitor parking “LO” level.

Phone: 604-299-1661
Fax: 604-299-1671
Email

Schedule an Appointment

Please contact our office by phone or complete the appointment request form below.
Our scheduling coordinator will contact you to confirm your appointment.
  • SELF REFERRAL

  • DOCTOR REFERRAL

Patient First Name:
Primary Contact (parent/guardian):
Gender:
Phone Number:
Insurance Information:
Patient Last Name:
Patient Age:
Referring Dentist:
Email:
Additional Information you would like to provide:

Download PDF

Date*

Introducing*

Patient Phone*

Appointment*

Doctor's Email*

Referring Office*

Phone*

Scale

Please enter the teeth affected:
Please Check

Consultation Only

Endodontic Treatment

Core Build Up

Post Space

Place Post

Close with Temporary

Close with Permanent

Sedation Required

Remarks

Doctor Signed*

Insurance Coverage

Primary Coverage

Carrier

Subscriber

DOB

Plan #

ID #

Secondary Coverage

Carrier

Subscriber

DOB

Plan #

ID #

Please provide us with a minimum of two business days notice to change or cancel an appointment in order to avoid any cancellation charges.

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840-2025 Willingdon Ave
Burnaby, BC V5C 0J3

Get Directions

Phone: 604-299-1661
Fax: 604-299-1671

Email

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