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appointment request

If you would like to make an appointment, please fill in the form and the office will contact you to confirm your choice of time.

**(* fields are required to be filled in)**

Salutation:

* First Name:

Last Name:

* Select Office for AppoIntment

Address:

City:

Province:

Postal code:

Phone:

Alternate Phone

* Email:

* Re-type Email:

Select One:
New Patient Current Patient

You will be contacted during business hours to set up an appointment

Best time of day to call:
......AM ......PM

Reason for Appointment:

Have you been diagnosed with sleep issues by a physician or sleep specialist?
......YES ......NO

Have you had a Sleep Study?
......YES ......NO

* I would like to be included on the Merrell Clinic e-mail list for perodical information and promotions emailings
......YES ......NO

Please enter the type you see above EXACTLY as it appears in ALL CAPS

Salutation:
* First Name:
Last Name:
* Select Office for AppoIntment
Address:
City:
Province:
Postal code:
Phone:
Alternate Phone
* Email:
* Re-type Email:
Select One:	New Patient Current Patient
You will be contacted during business hours to set up an appointment
Best time of day to call:	......AM ......PM
Reason for Appointment:
Have you been diagnosed with sleep issues by a physician or sleep specialist?	......YES ......NO
Have you had a Sleep Study?	......YES ......NO

* I would like to be included on the Merrell Clinic e-mail list for perodical information and promotions emailings	......YES ......NO

Please enter the type you see above EXACTLY as it appears in ALL CAPS