Time To Smile- Appointment Request
We're dedicated to providing essential dental care to community members in need, offering free extractions and hygiene appointments on select dates per year. Fill out the form below if you'd like to be contacted for our next Free Dental Day
Name of Patient
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
*note we offer Free Dental Days for both adults and children
Phone Number
*
*parent or guardian phone number if patient is a minor
Format: (000) 000-0000.
Email
*
*parent or guardian email if patient is a minor
Please provide any information on what kind of dental care the patient may need
*
Submit
Should be Empty: