Book a Dental Appointment

Client information

* Child's date of birth Year 20242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999 Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day 12345678910111213141516171819202122232425262728293031

* Does your child have Healthy Smiles Ontario? Yes
No
If your child's Healthy Smiles Ontario card is expired, please select No

* Did your child participate in dental screening this school year at their school or child care centre? Yes
No

Notice of Collection

Any personal information or personal health information submitted will be collected, used, and disclosed, where applicable, by members of Regional staff according to the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act. Any information you share will only be used for the intended purpose for which it was provided.

For questions or comments about privacy practices, or for more information about the administration of the Municipal Freedom of Information and Protection of Privacy Act in Niagara Region programs, see Freedom of Information and Open Government.