Cor-dent Dental Centre - Schedule an Appointment

Name:		Email:
Address:		Postal Code:
City:
Home or Cel Phone#:		Business/Daytime#:
Scheduling Preference (e.g. day and time you prefer -- our office will call to confirm your appt.)
Preferred Dentist	[ ] Dr. Ling [ ] Dr. Patel [ ] Dr. Eyer [ ] Please choose for me!
How did you hear about CorDent? (If you saw one of our print ads, please list the publication - thank you!)	e.g. Internet Search (e.g. Google, Yahoo), Friend or Family, Advertisement, Magazine Ad, Walking/Driving by, Other (please specify).