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2891 Old Lakeshore Rd, Brights Grove, ON N0N 1C0, Canada
We are open 7 days a week from 7am to 9pm
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[wpforms id="6816" title="false" description="false"]
<div class="wpforms-container wpforms-container-full" id="wpforms-6816"><form id="wpforms-form-6816" class="wpforms-validate wpforms-form" data-formid="6816" method="post" enctype="multipart/form-data" action="/contact/" data-token="95a1402ced8b018c892230b2800ad7f2"><noscript class="wpforms-error-noscript">Please enable JavaScript in your browser to complete this form.</noscript><div class="wpforms-field-container"><div id="wpforms-6816-field_10-container" class="wpforms-field wpforms-field-name" data-field-id="10"><label class="wpforms-field-label" for="wpforms-6816-field_10">First Name <span class="wpforms-required-label">*</span></label><input type="text" id="wpforms-6816-field_10" class="wpforms-field-large wpforms-field-required" name="wpforms[fields][10]" required></div><div id="wpforms-6816-field_12-container" class="wpforms-field wpforms-field-name" data-field-id="12"><label class="wpforms-field-label" for="wpforms-6816-field_12">Last Name <span class="wpforms-required-label">*</span></label><input type="text" id="wpforms-6816-field_12" class="wpforms-field-large wpforms-field-required" name="wpforms[fields][12]" required></div><div id="wpforms-6816-field_11-container" class="wpforms-field wpforms-field-email" data-field-id="11"><label class="wpforms-field-label" for="wpforms-6816-field_11">Your Best Email <span class="wpforms-required-label">*</span></label><input type="email" id="wpforms-6816-field_11" class="wpforms-field-large wpforms-field-required" name="wpforms[fields][11]" required></div><div id="wpforms-6816-field_13-container" class="wpforms-field wpforms-field-divider" data-field-id="13"><h3 id="wpforms-6816-field_13" name="wpforms[fields][13]">Section Divider</h3></div><div id="wpforms-6816-field_8-container" class="wpforms-field wpforms-field-checkbox" data-field-id="8"><label class="wpforms-field-label" for="wpforms-6816-field_8">Vote For Your Favorite Dentist (help us display the best dentists)</label><ul id="wpforms-6816-field_8" class="wpforms-randomize"><li class="choice-1 depth-1"><input type="checkbox" id="wpforms-6816-field_8_1" name="wpforms[fields][8][]" value="Edgewater Dental" ><label class="wpforms-field-label-inline" for="wpforms-6816-field_8_1">Edgewater Dental</label></li><li class="choice-2 depth-1"><input type="checkbox" id="wpforms-6816-field_8_2" name="wpforms[fields][8][]" value="Great Lakes Dental" ><label class="wpforms-field-label-inline" for="wpforms-6816-field_8_2">Great Lakes Dental</label></li><li class="choice-3 depth-1"><input type="checkbox" id="wpforms-6816-field_8_3" name="wpforms[fields][8][]" value="Chagger Dental Petrolia" ><label class="wpforms-field-label-inline" for="wpforms-6816-field_8_3">Chagger Dental Petrolia</label></li><li class="choice-11 depth-1"><input type="checkbox" id="wpforms-6816-field_8_11" name="wpforms[fields][8][]" value="Lambton Family Dental" ><label class="wpforms-field-label-inline" for="wpforms-6816-field_8_11">Lambton Family Dental</label></li><li class="choice-10 depth-1"><input type="checkbox" id="wpforms-6816-field_8_10" name="wpforms[fields][8][]" value="Chagger Dental Wyoming" ><label class="wpforms-field-label-inline" for="wpforms-6816-field_8_10">Chagger Dental Wyoming</label></li><li class="choice-9 depth-1"><input type="checkbox" id="wpforms-6816-field_8_9" name="wpforms[fields][8][]" value="Dr. Vanessa Curran" ><label class="wpforms-field-label-inline" for="wpforms-6816-field_8_9">Dr. Vanessa Curran</label></li><li class="choice-8 depth-1"><input type="checkbox" id="wpforms-6816-field_8_8" name="wpforms[fields][8][]" value="Dr. Jessica Bourassa" ><label class="wpforms-field-label-inline" for="wpforms-6816-field_8_8">Dr. Jessica Bourassa</label></li><li class="choice-7 depth-1"><input type="checkbox" id="wpforms-6816-field_8_7" name="wpforms[fields][8][]" value="Clearwater Family Dental" ><label class="wpforms-field-label-inline" for="wpforms-6816-field_8_7">Clearwater Family Dental</label></li><li class="choice-6 depth-1"><input type="checkbox" id="wpforms-6816-field_8_6" name="wpforms[fields][8][]" value="MacNeill & Spinnato Dentistry" ><label class="wpforms-field-label-inline" for="wpforms-6816-field_8_6">MacNeill & Spinnato Dentistry</label></li><li class="choice-5 depth-1"><input type="checkbox" id="wpforms-6816-field_8_5" name="wpforms[fields][8][]" value="Lefebvre Dentistry" ><label class="wpforms-field-label-inline" for="wpforms-6816-field_8_5">Lefebvre Dentistry</label></li><li class="choice-4 depth-1"><input type="checkbox" id="wpforms-6816-field_8_4" name="wpforms[fields][8][]" value="Lakeshore Family Dental" ><label class="wpforms-field-label-inline" for="wpforms-6816-field_8_4">Lakeshore Family Dental</label></li><li class="choice-12 depth-1"><input type="checkbox" id="wpforms-6816-field_8_12" name="wpforms[fields][8][]" value="Brights Grove Dental" ><label class="wpforms-field-label-inline" for="wpforms-6816-field_8_12">Brights Grove Dental</label></li></ul></div><div id="wpforms-6816-field_19-container" class="wpforms-field wpforms-field-divider" data-field-id="19"><h3 id="wpforms-6816-field_19" name="wpforms[fields][19]">Section Divider</h3></div><div id="wpforms-6816-field_7-container" class="wpforms-field wpforms-field-textarea" data-field-id="7"><label class="wpforms-field-label" for="wpforms-6816-field_7">Missing Your Favorite Dentist? (let us know here)</label><textarea id="wpforms-6816-field_7" class="wpforms-field-small" name="wpforms[fields][7]" ></textarea></div></div><div class="wpforms-submit-container" ><input type="hidden" name="wpforms[id]" value="6816"><input type="hidden" name="wpforms[author]" value="4"><input type="hidden" name="wpforms[post_id]" value="18"><button type="submit" name="wpforms[submit]" class="wpforms-submit " id="wpforms-submit-6816" value="wpforms-submit" aria-live="assertive" data-alt-text="Sending..." data-submit-text="Submit">Submit</button></div></form></div> <!-- .wpforms-container -->
