Existing Patient Appointment Management & Communication Form

Existing Patient Appointment Management & Communication Form

We value your time and aim to make scheduling and communications simple and efficient. This form is for existing patients who need to request an appointment, reschedule an appointment, or submit an non-urgent question. After submitting the form, our team will review your request and respond by text, email or phone during regular business hours. Appointment requests are not confirmed until you receive confirmation from our office.
Name

First NameLast Name
Email
example@example.com
Phone Number
We will contact you via text with available appointment times.Format: (000) 000-0000.
What can we help you with?
Please briefly describe your request.
Administrative Questions

Administrative quesstions may be answered by text or email.

For billing or payment related questions, please contact the office by email (frontoffice@32pearlsfamilydental.com) whenever possible. Email allows us to securely review and respond with supporting documentation, including insurance information, receipts, and account details.

For questions that require more detailed information, we may recommend email communication, as it provides a written record that can be referenced by both the patient and our team.

Questions requiring clincial evaluation, diagnosis, treatment recommendations, or treatment planning may require an appointment.
What day of the week or time works best for you? Please remember that we are open Mondays, Wednesdays, and Thursdays. We will do our best to accommodate your preferences, but availability may vary
Would you prefer our first available appointment or do you have a specific time frame?

Other
If you selected "other" to the above question, please tell us your preferred time frame? Example: "3rd week of May, mornings only"
If you are using insurance, has your insurance changed since your last visit?
If your insurance has changed since your last visit you must email a copy of the front and back of your insurance card to

frontoffice@32pearlsfamilydental.com

If your insurance information is missing , or not received within 48 hours of your appointment, you will be charged the full fee at the time of service.
AFTER-HOURS CARE

Messages submitted outside of our regular business hours will be reviewed during the next business day.

Our office does not provide after-hours emergency appointments. Dental concerns are evaluated and scheduled based on clinical urgency and appointment availability.

If you are experiencing severe swelling difficulty breathing, difficulty swallowing, uncontrolled bleeding, or another medical emergency, seek immediate medical attention or call 911.
Should be Empty: