Toronto Dental Group

	Full Name of Patient:


	Email:


	Phone number where we can reach you:


	I am an:
	Existing patient	New patient

	Preferred days of the week that you can see us:
	Monday
	Tuesday	Preferred time of day:
	Wednesday	Morning
	Thursday	Mid-day
	Friday	Afternoon

	What is the purpose of your visit:

Dr. Jeremy Kurtz DDS