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TO BOOK A CONSULTATION,
CALL
1-514-935-9906
or |
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E-mail us the completed form by
clicking submit |
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v
Name: |
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Date Of Birth: |
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| v
Address: |
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| vCity: |
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State |
Country |
| vZip
Code: |
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| vPhone: |
(Home) |
(Office) |
| vFax
Number |
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| vE-mail: |
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| Preference for
type of consultation (Check one answer): |
|
Consultation with Doctor
Fanous $100 CAN
(refundable if any treatment is taken)
Free
consultation
with
assistant |
| Preference
of time (check one answer) : |
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AM PM |
| Preference
of day (check all possible days) :
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Monday
TuesdayWednesdayThursdayFriday
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*Someone from our
Clinic will contact you within 2-3 days to confirm your appointment.
Thank you.
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