Form

In Office Appointment Request Form (Existing Patient)

Please note: In office hours and appointments may be limited due to COVID-19 and a shortage of PPE. Virtual appointments are available to triage as many patients as possible under these unprecedented circumstances. Many patients can be given prescriptions, home remedies/solutions until an appointment for treatment is available.

First Name

Last Name

Phone #

Email Address

Comments: If you are requesting a consultation or have a dental emergency please specify your concern so we may appoint you properly.

Preferred time of appointment:

Preferred day of the appointment (select all appropriate)

Please tell us how you heard about us, we would appreciate if you provide additional information in the comments box below.

Date Of Birth

Do You Have Insurance?

Insurance Company

Insurance ID or Social Sec. #

Upload A Photo of Yourself or Your Insurance Cards Below

Upload or drag files here