Javascript must be enabled for the correct page display

Request an Appointment

Please use this form to request an appointment.

Submitting this form does not guarantee or secure an appointment. We will contact you to confirm your visit. Please do not use this form in an emergency.
After submitting this form, please wait to hear back from us before heading in for your visit. Please note that this form is not intended for emergencies or urgent requests.

You may also contact our office at (289) 216-9718 or email us at [email protected].

Your Name

Your Phone

Your Email

Patient's Name

Preferred Time of Day

Message

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Image CAPTCHA

What code is in the image?

Enter the characters shown in the image.

Get new captcha!