Time To Smile- Appointment Request
We're dedicated to providing essential dental care to the Veterans and first responders that have served our community, 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 Free Dental Day on November 7th
Name of Patient
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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
*
Please provide any information on what kind of dental care you may need
*
Submit
Should be Empty: