Appointment Inquiry Form

Appointment Inquiry Form

RECEIVE A FREE GIFT CARD FOR VISITING A HEALTHX DENTIST
Am I The Right Candidate?
- You book and complete a new patient exam and cleaning with a HealthX Dentist (General or Free consultations do NOT qualify for rewards)
- You are not an existing patient of the dental clinic or have not claimed a HealthX reward in the past 2 years.
- You are at least 18 years old on the date of your appointment.
- Your appointment was booked using the name on your HealthX form submission. If one form was used to book appointments or two or more patients, only one patient will be able to claim a reward.
- Please note that your receipts/walk-out statements must be submitted to HealthX Canada Inc. for verification purposes: https://form.jotform.com/220033280415340
- Exclusions: ODSP and OW
Please choose your preferred Gift Card/Membership:*

$150 Amazon Gift Card$150 Apple Gift Card$150 Best Buy Gift Card$150 Alo Gift Card$150 Uber/Uber Eats Gift Card$150 Winners/Marshalls/HomeSense$150 Zara Gift Card$150 Sephora Gift Card$150 Starbucks Gift Card
Please choose your preferred location(s):*

Bite Dental (106 Mutual St, TORONTO)Y & F Dental (26 Wellington St E, Unit #110, TORONTO)Grimsby Lake Dental (414 Winston Rd, Grimsby)West Ajax Dental & Prosthodontics (73 Old Kingston Rd, AJAX)Westdale Dentistry (875 Main St W, HAMILTON)Dentistry On Finch (3443 Finch Ave E Suite 206, Scarborough)Dentistry by The Bay (220 Dundas St E, BELLEVILLE)Clear View Dental (427 Dundas St W, TRENTON)
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Preferred Appointment Date*
Reason for your appointment/visit:

New Patient Exam and CleaningCDCP New PatientOther
Notes for the dental office:
By signing this form, HealthX Canada Inc. will use information you provide to deliver you relevant information about our services, including offerings based on your preferences. To learn more, see our privacy policy. By signing this form, you are agreeing to the Terms of Use and Privacy Policy.
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