Online registration Please note, appointments are 3 hours in length and often more than one appointment is required. Also, it may be several weeks before you hear about an appointment. If you have been on the list for a while without being contacted please email email@example.com. Name* First Last Birthdate* MM slash DD slash YYYY Home phoneCell phoneEmail* Is there another family member you would like to add? Yes Family member informationNameBirthday Preferred method of contact* Email Home phone Cell phone When was your last dental cleaning?* Less than 6 months 6-12 months 1-2 years 3-5 years 5-10 years 10+ years Have you attended our clinic before?* Yes No How did you hear of our dental clinic? Family/friend referral Facebook page Brochures Newspaper Ad Internet Community agency Oral Health Unit/Healthy Smiles NameThis field is for validation purposes and should be left unchanged.