Request an Appointment

Request an Appointment
Please note that a referral from a doctor is not required for and parent’s may submit a request themselves.

This form can be used by:

EXISTING PATIENTS IN TREATMENT -OR- for NEW PATIENTS

This is a general request form to communicate to us that you would like us to contact you to help set up an appointment. Please note that a referral from a doctor is not required. Our team typically responds within two business days.

This form should not be used for dental emergencies.
Today's Date*

MonthDayYear
Date
Patient Status*
Patient Name*

First NameLast Name
DOB*

MonthDayYear
Date
Name of Person Providing Information For This Form*
Relationship to Patient*
Contact Phone Number To Reach You*
Please enter a valid phone number.
Email Address To Reach You*
example@example.com
Existing Patients: skip to the end of the form, enter comments and submit form.
Select An Option That Best Describes The Type Of Consult Needed

Young ChildPre-TeenTeenAdult
Select All Options That Describe Reasons For Consult

Dentist Recommended ConsultNo Concerns, Seeking General ConsultSeeking a Second OpinionTransfer From Another Practice During Ongoing TreatmentAlignment of Teeth & Smile ImprovementCorrection of Bite ProblemsCrowded TeethNarrow Palate/Upper JawCrossbiteGaps Between TeethImpacted TeethMissing TeethAlign Teeth Prior to Dental Work (Crowns/Implants)Wants to Resolve TMD/TMJ ProblemsNeed a New Retainer/Night Guard
Please enter reasons for requesting an appointment and any comments that may help us understand how best to schedule your child:*
Optional: You may upload images such as X-rays, a copy of the front and back of your dental insurance card, & any previous dental chart notes.
File Upload

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File Upload

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IMPORTANT NOTE FOR NEW PATIENTS: We will contact you and guide you through the next steps, which will include completion of our new patient registration form.
Should be Empty: