Appointment Request

  1. 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.
  2. Salutation(*)
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  3. First Name(*)
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  4. Last Name(*)
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  5. Select Office for Appointment(*)
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  6. Address(*)
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  7. City(*)
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  8. Province(*)
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  9. Postal Code(*)
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  10. Phone(*)
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  11. Alternate Phone
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  12. Email(*)
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  13. Select One
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  14. Best time of day to call
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  15. Reason For Appointment
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  16. Have you been diagnosed with sleep issues by a physician or sleep specialist?
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  17. Have you had a Sleep Study?
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  18. I would like to be included on Merrell Clinic e-mail list for periodical information and promotions emailings
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  19. Captcha(*)
    Captcha
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