If you would like to request an appointment, please fill out this form below. Thank you.

*Name:
*Address:
*City:
*Province:
*Postal Code:
*Home Telephone:
*Work Telephone:
*Email:
*Purpose of Visit:

 

NOTE: The information that you provide using this request for appointment form is not stored on a secure server. Therefore, we have no way of guaranteeing the security or the privacy of your information. If you do not wish to provide this information, using this form, please contact our office directly at (403) 264-FACE (3223)

PRIVACY STATEMENT
The personal health information that you provide to Therapeutic Skin Solutions is collected, used and disclosed in accordance with the provisions of the Health Information Act (HIA), and is used to provide diagnostic, treatment and care services to you, and to bill Alberta Health Care for services provided.