Appointment Request

The first step towards a beautiful, healthy smile is to schedule an appointment. Please contact our office by phone or complete the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment.

Please do not use this form to cancel or change an existing appointment.

*Items in bold are required.

Name:

Are you a current patient?
 Yes No

Address:

City:

State/Province:

Zip/Postal:

Email:

Phone:

Best time(s) to call?
 Morning Noon Afternoon Evening

Preferred day(s) of the week for an appointment?
 Any Day Monday Tuesday Wednesday Thursday Friday

Preferred time(s) for an appointment?
 Any Time Morning Noon Afternoon Evening

Please describe the nature of your appointment (e.g., consultation, check-up, etc.):

captcha