Request an Appointment

Accepting New Patients

We’ve provided this form for you to request dental appointments. First-time patients can also print and fill in our new patient form at home if convenient. Please do not use this request form to reschedule existing appointments. If you need to reschedule an existing appointment, please call our office Monday through Thursday during our regular business hours. We also advise you to call for any and all dental emergencies. Do not use this form for any urgent requests.

Request an Appointment

Name*
First Last
Phone*
Email*
Patient Status*
Please check applicable box.
- Current Patient
- New Patient
Select Preferred Day for Appt*
Please let us know which is better day for you.
Reason for Appointment*
Please check box that most closely applies.
- Check up
- Teeth Cleaning
- Consultation
- Second Opinion
Select Preferred Time of Day for Appt*
Unless you select "anytime" please note office hours: 8:30 am to 5:00 PM, Monday through Thursday.
Referral
Please let us know who or from where you were referred to us.
Additional Comments
Please let us know anything else you would like us to know when we schedule your appointment.
Name
This field is for validation purposes and should be left unchanged.

Appointment requests are answered promptly; usually in less than 24 hours. Sending this form is simply a request for a dental appointment. You are under no financial obligation. You can also be certain that our office observes HIPAA Federal Regulations, which protect your privacy.

We will never release any information about you without your consent. We are allowed to release information to your insurance company, however, or as necessary to receive payment for our dental services. Please know you can always gain access to your patient records simply by asking us.