Dental Hygiene Appointment Request
Thank you for choosing OraSmile Dental Hygiene Clinic for your preventive dental care needs. Please submit this encrypted form with your preferred dates and times and we will get back to you shortly.
Treatment Requested:
Please Select
Dental Hygiene Therapy ( dental cleaning and oral health evaluation )
Teeth Whitening ( Professional In-Office * Dentist Prescription Required )
Kids & Teen Dental Hygiene Therapy ( age 0-17 )
Laser Bacterial Reduction ( Supportive therapy for maintaining health gums )
Preventive Sealants ( age 0-99 )
Desensitization Treatments
Patient Name
*
First Name
Last Name
Guardian ( if patient is under age 14 )
First Name
Last Name
Age of Child ( if applicable )
E-mail
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
ex: GOOGLE, Facebook, Instagram, Family / Friends, Existing Patient
Preferred Appointment Date & Time
* Please indicate your preferred date and time. This request will be reviewed an approved based on availability.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time Requested: ( Morning, Afternoon, Evening, Weekend )
OraSmile is a certified Guided Biofilm Therapy provider. Watch "GBT" in action and prepare yourself for an amazing transformation! You deserve it!
Submit appointment Request
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