CONSULTATION Inquiry Request Form
Name, Home phone number and eMail required
v Name:  
v Date of birth:  
v Address:  
v City:  
     
   


Prov

  


Country
v Zip Code:  
     

a phone number (at home, at the office, or a cellular) which would allow us to contact you during the day between 8 a.m. and 5 p.m.
v Phone:  
Home (*)
Office
     
Best time to reach me :   Monday Tuesday Wednesday Thursday Friday
    AM (morning 8h-12h) PM (afternoon 1h-5h)
     
v Fax number:  
     
v e-Mail:  
     
Preference for type of consultation (Check one answer):
    Consultation with Doctor N.Fanous $100 CAN
     (refundable if any treatment is taken)
Free consultation with coordinator
     (Available on monday only)
     
Preference of time (check one answer):
    AMPM
     
Preference of day (check all possible days):
    Monday Tuesday Wednesday Thursday Friday
     
E-mail us the completed form by clicking .: submit :.
     
 

 

A member of our staff will contact you within 2-3 days to confirm your appointment. Thank you.