Appointment Request Form
(Non-Medicaid / Existing Patients)
Are you an existing patient of Dr. Roberts? If you are a new patient, do you have non-medicaid primary dental insurance?
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I am an existing patient
I am a new patient, but I have non-medicaid commercial dental insurance
I am a new patient, but I do not have dental insurance
If you are a new patient, what type of dental insurance do you have? (What insurance company)
Name
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First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Birthday
*
-
Month
-
Day
Year
Date
Which of these best describes your dental needs? (Please note if you are concerned with non-painful cavities, please select a cleaning option)
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I need a cleaning and exam. I have never been told I need a deep cleaning/have seen a dentist in the last 3 years.
I need a cleaning and exam. I have been told in the past I have gum disease or need a deep cleaning. It has been 5+ years since I have seen a dentist.
I have a specific tooth bothering me and would like that tooth only addressed.
I need dentures
Other
If you selected "other" to the question above, please leave a brief description of your dental needs.
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What days and times for an appointment would work best for your schedule?
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Monday Morning (8-11)
Monday Afternoon (1-4)
Tuesday Morning (8-11)
Tuesday Afternoon (1-3)
Wednesday Morning (8-11)
Wednesday Afternoon (1-3)
Thursday Morning (8-11)
Thursday Afternoon (1-3)
Submit
Should be Empty: