CONSULTATION REQUEST FORM

v Name:

v Date of birth:

v Address:

v City:

Prov

Country

v Zip Code:

v Phone:

Home

Office

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

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 :.

Someone from our staff will contact you within 2-3 days to confirm your appointment. Thank you.