Appointment Request
We’ll contact you to confirm your appointment date and time. Same-day appointments are not guaranteed.
Are you a new or existing patient?
*
New Patient (First visit to Wildwood Dental Clinic)
Existing Patient (Have been seen here before)
What type of appointment do you need?
*
Routine Checkup & Cleaning
New Patient Exam
Dental Emergency
Cosmetic Consultation
Specific Treatment
Children's Appointment
Other
First Name
*
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Date
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Month
-
Day
Year
Date
Alternate Date
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Month
-
Day
Year
We will prioritize your preferred date; however, including an alternate date helps us offer more availability if your first choice is full.
Preferred Time of Day
Morning (7:30 am - 12:00 pm)
Afternoon (12:00 - 5:00 pm)
Evening (5:00 until 8:00 pm)
No Preference (Any available time)
Coverage Type
Please Select
Private Insurance
Government Plan
Self-Pay
Other
How did you hear about us?
Please Select
Friend or Family
Google / Online Search
Social Media
Another Dentist / Doctor
Other
Concerns or notes
This is an appointment request, not a confirmed booking. We'll contact you within one business day to confirm your time. For urgent dental concerns, call us directly at 306.374.7272.
Submit Appointment Request
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