Request an Appointment

The first step toward a healthy, confident smile is scheduling your child’s visit. Please complete the form below to request an appointment, and one of our scheduling coordinators will reach out to confirm details, answer any questions, and help with scheduling your visit.

This form is for appointment requests only. Once received, a member of our team will give you a call during business hours to schedule.

If you need to cancel or reschedule an existing appointment, or if you require immediate attention, please contact our practice directly.

Contact Information

Contact Name *

First and Last

Address Line 1 *

Address Line 2

City *

State/Province *

Zip Code *

Phone Number *

Patient Information

Patient Name *

First and Last

Date of Birth *

MM/DD/YY

Appointment Information

Preferred Appointment Date *

MM/DD/YY

Preferred Time

Children in pre-school and elementary grades are usually seen in the morning. Late afternoon appointments are reserved for middle and high school age patients.

Referral Source

Dental Insurance Provider

Comments

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