gift referral

Gift Refer a Friend

Please complete the form below, should you want to gift transfer to a family member, friend or colleague.

You are welcome to gift refer more than one friend, colleague or family member (not residing at the same address as you).

* Indicates required field

Name of patient referring a Gift (sender) *

First

Last

Email of existing patient (sender) *

Mobile phone Number of existing patient (sender) *

We regret: only mobile numbers are accepted for authenticity and security purposes.

Name of Gift recipient (person you are gifting) *

First

Last

Email of Gift recipient *

Mobile phone Number of Gift recipient *

We regret: only mobile numbers are accepted for authenticity and security purposes.

Submit

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44-C Main Street East, Chelmsford, Ontario

Office hours:
(Monday 8am - 8pm) (Tuesday 8am - 8pm) (Wednesday 8am - 8pm) (Thursday 8am - 5pm) (Friday 8am - 2pm)

Telephone

+1 705-855-3510

Email

gdental@eastlink.ca

email us

Please bring the following to your first dental visit:
Your completed patient information form
Your insurance card

patientform.pdf
File Size:	244 kb
File Type:	pdf

Download File

Financial Policy:
We do not offer a payment plan but we do have a dental financing company that does. Information is available at Dental Card or please call 1-888-689-9876 for details. We accept all Visa, Mastercard, American express and debit cards, and most insurance plans. We charge using last year's fee guide to help our patients in the current economic situation.

Cancellation and No Show Policy:
We require at least a 24 hour notice for any cancellations. After 24 hours, a fee is charged, which will not be covered by the insurance.

Gift Refer a Friend

We Would Love to Have You Visit Soon!

FREE E-book reads

Telephone

Email