Appointment form Please answer this short questionnaire as accurately as possible, so that we can process your application quickly. Reason for consultation * ---Emergency treatmentDental check-upHygienist careGum treatmentDental implant placementTMJ problemWisdom toothAesthetic treatmentTreatment for children Description of your request * Availability * Morning (from 8am to 2pm) MondayTuesdayWednesdayThursdayFriday Afternoon (from 14h to 19h) MondayTuesdayWednesdayThursdayFriday Do you have a phobia about dental care? * YesNo Are you already a patient of Centre Dentaire Champel? * YesNo Civility * Ms.Mr. Name * First name * Phone * E-mail * Address NPA City Locality Personal data management * I accept the Privacy Policy : Read our Privacy Policy * : mandatory field
