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New Patient Appointment Request

Please provide the following information for ALL children on ONE form so we can find an appointment that works for your family: Please provide the following information so we can find a day/time that works for you:

Clinic Location you would like to book at
Burlington
Milton
Stoney Creek
Number of Children in the family you wish to book
1
2
3
4
5+
Clinic Location you would like to book at
Burlington
Milton
Stoney Creek
Our office hours are Monday to Friday 8:00 a.m. to 5:00 p.m. NO WEEKENDS. Do you have a preferred day of the week ? Please check all that apply. (Please note, our Stoney Creek location is not currently open on Mondays)
Is there a preferred time of day that works best? Please check all that apply.

Please note that as a pediatric dental office all of our patients are children and a large portion of them are school aged.  Our busiest times are before and after school (after 3pm). HOLIDAYS and on PA days so availability of these appointments is limited. If the next appointment we have available on the specified day/time that you request is more than a few weeks out, at your request, we can put them on our cancellation list and give you a call when something opens up earlier.

What is the reason for the appointment(s)?
Will you be using the Canada Dental Care Plan to help pay for this appointment?
Yes
No

Information you should know: 

Safari Children's Dentistry is a Pediatric Specialist office and as such follows the Ontario Dental Associations recommended fee guide for Certified Paediatric Dentists.  If you are unsure of what your insurance policy covers, please give them a call or check online for:

  • the fee guide covered by your insurance (the year and type of practitioner i.e. specialist/general practitioner)

  • your plan maximum - including time frame (i.e. calendar year or September to August)

  • the percentage of the fees that your policy covers

  • frequencies for: new patient exams, recall exams, scaling, polishing and fluoride

Safari Children's Dentistry will directly bill most work and private insurance policies provided that the plan allows for it. Office policy requires that a credit card is left on file with us in order to direct bill as a security measure - if you would prefer not to leave a card on file, you can pay the total amount at the end of the appointment and we will send the claim to your insurance for them to pay you back directly.  All known balances are required to be paid at the end of the appointment.

Safari Children's Dentistry does accept the Canada Dental Care Plan (CDCP) HOWEVER there will be a co-pay regardless of your coverage level (even if 100% of the CDCP fee guide).

Safari Children's Dentistry does NOT accept Healthy Smiles Ontario (HSO) at our offices.

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