Appointment Inquiry Form

Appointment Inquiry Form

HealthX Canada Inc. is a marketing and referral platform and is not a healthcare provider. This form is used only to verify eligibility for promotional rewards. Please do NOT submit clinical records, X-rays, treatment plans, diagnostic reports, or insurance claim details. By submitting this form, you confirm you understand that HealthX does not require clinical health information.
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 book and complete an INITIAL CHIROPRACTIC CONSULTATION and FOUR SUBSEQUENT TREATMENTS at a HealthX chiropractor (General or Free consultations do NOT qualify for rewards)
- You are not an existing patient of the dental or chiropractic 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.
- Receipt submission link
- Exclusions: ODSP, OW, WSIB and MVA
Please choose your preferred Gift Card/Membership:*

$200 Amazon Gift Card$200 Apple Gift Card$200 Best Buy Gift Card$200 Uber/Uber Eats Gift Card$200 Winners/Marshalls/HomeSense$200 Zara Gift Card$200 Sephora Gift Card
Please choose your preferred dental 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)
Please choose your preferred chiropractic location(s):*

JawSpine Centre (26 Wellington St E, Unit #110, Inside Y&F Dental, TORONTO)
Name*

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

Initial Regular Chiropractic ConsultationInitial TMJ Chiropractic ConsultionNew Dental Patient Exam and CleaningOther
Notes for the dental/chiropractic 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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