Appointment Inquiry Form

Appointment Inquiry Form

HealthX Canada Inc. is a marketing and referral platform and is not a healthcare provider. All clinical decisions are made by your treating dental provider.
Am I The Right Candidate?
- You must complete an initial new patient visit, including any clinically necessary diagnostic and preventive services as determined by the treating 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.
- Proof of visit may include a receipt or document showing your name, clinic name, and visit date. Please do NOT submit X-rays, clinical notes, treatment plans, or insurance claim details.
- Exclusions: ODSP and OW
Please choose your preferred Gift Card/Membership: (Gift cards are issued by third-party vendors and are subject to vendor terms and availability.)*

$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)SR SmileCare Dental (2190 Warden Ave. suite 205, 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*
Appointment Type (Non-Clinical Selection Only):

New Patient AppointmentGeneral Appointment InquiryOther (Non-Clinical)
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. I understand that HealthX Canada Inc. will use my information to coordinate appointment inquiries and verify promotional eligibility. I understand that I should not submit clinical health records or diagnostic information through this form.
Signature*

Clear
Should be Empty: