Make an Appointment Are you a new patient? No Yes Reason for your visit Dental Cleanings Dentures or Implants Cosmetic – Teeth Whitening, Veneers, Bonding, etc. Dental Consultation (second opinion or Invisalign) Dental Emergency Are you experiencing pain, swelling, or bleeding? Yes No Pain Location Rate Your Pain 1 2 3 4 5 6 7 8 9 10 Other Other reason for visit Appointment Time Preferred Day and Time First Available Specific Day(s) M T W Th F Morning Afternoon Monday Morning Tuesday Morning Wednesday Morning Thursday Morning Friday Morning Monday Afternoon Tuesday Afternoon Wednesday Afternoon Thursday Afternoon Friday Afternoon Additional Information (optional) Patient Information First Name Last Name Date of Birth Contact Information Email Address Phone Number Contact preference Email Phone Do you have insurance? No Yes Insurance Provider Do you require any special accommodations? No Yes Details In order to request an appointment you must be 13 years of age or older. Yes, I am 13 years of age or older Thank You We will be in touch as soon as possible. If you chose email as your primary contact method, please watch for an email confirmation to follow. While you’re here, please tell us how you heard about us. Patient Referral Patient’s Name Website/Google search, etc. 1-800 Dentist (per referral) Location/Drive By/Sign Daily Deal/Groupon Insurance Company Yellow Pages Print Other Marketing How did you hear about us?