Hazel Park - 2024 Corktown Health Dental Clinic Scheduler

Corktown Health Dental Clinic Scheduler

at Hazel Park Community Center (620 W Woodward Heights Blvd)
Name*

First NameLast Name
First Name Used
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Do you have Dental Insurance?*

YesNo
Name of Dental Insurance
If you have dental insurance, please bring your dental insurance card to the appointment.
Which dental service would like to receive? (Select one only)*

Dental ExamX-RayTeeth CleaningSealantsFluoride TreatmentsFillingsDental Referrals
Get Your Appointment (Appointments are approximately 1.5 hrs)*
By submitting I hereby confirm that the information I have given above is true.

By submitting I hereby understand the appointment is scheduled for approximatley 1.5 hrs.

By submitting I hereby agree to arrive to arrive 15 minutes before my scheduled appointment.

By submitting I agree if I am unable to make the appointment, I will call 313-832-3300 x260 and cancel the appointment at least 48 hrs before the appointment.
Please verify that you are human*
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