Form

Appointment Request

Please note that this form does not guarantee an appointment: we will contact you to confirm your appointment, or in the event that we are unable to book you during your requested dates, we will contact you to determine a better fit. We look forward to hearing from you!

First Name

Last Name

Phone

Date Of Birth

Have you visited us before?

Do you need to update your insurance on file?

Do you have dental insurance or will you be paying for yourself?

Insurance Information:

Primary Dental Insurance: Type of Plan

What type of funded policy?

Emloyer Name:

If other:

Insurance Company Name:

Subscriber ID/Member #:

Group Number:

Front of Dental Insurance Card:

Upload or drag files here

Back of Dental Insurance Card

Upload or drag files here

NOTE: There is currently a Nationwide hygienist shortage. The current estimated wait-time for a New Patient Exam/Cleaning is approximately 4-6 Months. Once scheduled, our office offers a cancellation list for a sooner-if-possible appointment. These notifications are sent out via text & email.

Please explain

When was your last dental cleaning/exam?

Concerns to be addressed at this appointment:

Preferred time of appointment (choose all that apply):

Preferred day of appointment (choose all that apply):

If your requested time is unavailable, would you like to be added to a cancellation list for a "sooner-if-possible" appointment?

If Other:

Additonal Comments: