Book An Appointment

Appointment Request

This is not a reservation of an appointment but only an appointment request. Someone on our side will contact you shortly to confirm your next appointment day and time.

Name*

First Middle Last

Email*

Telephone*

Please insert the best phone number to reach you at.

I want an appointment as soon as possible.

Appointment Time Preference

Appointment Day Preference*

Please choose your preferred day of the week

Appointment Time Preference*

Reason For Booking Appointment*

Please state a brief description of the reason for booking the appointment.

How Did You Find Us?

How Did You Find Us?*

If Selected 'Other' Above, Please Specify:

Are You A New Patient?

Are You A New Patient?*

New Patient Information

Work Phone Number

Cell Phone

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Health Information

Date Of Last Dental Visit*

Reason For This Visit*

Please state a brief description for the reason of this dental visit

Have you ever had any of the following? Please check those that apply:*

Please Specify Allergies If Any:

If Pregnant Please Specify Due Date:

If Taking Medication Please Specify Type of Medication:

Have you ever had any complications following dental treatment?*

If yes, please explain:

Have you been admitted to a hospital or needed emergency care during the past two years?*

If yes, please explain:

Are you now under the care of a physician?*

Name of Physician:

First Name Last Name

Phone Number of Physician:

Do you have any health problems that need further clarification?

If yes, please explain:

Health Information Consent*

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

I agree that all of the information provided in this form is true & correct

Referral Information

Whom may we thank for referring you to our practice?*

Name of person or office referring you to our practice (if any)

Employment Information

The following is for:*

Employer Name:*

Occupation:*

Consent For Services

Consent For Services*

Welcome to our Dental Office.

As a condition of your treatment by this office, we expect payment on the day of service.Patients who carry dental insurance understand that all dental services completed that day are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms and with your permission will send your insurance claim electronically to your insurance company. You will receive payment from your insurance company within 5-7 days.

Our office expects and would appreciate 48 hours notice for any appointment changes.

I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to their content.

I Consent For These Services