Contact Us
The first step towards a beautiful, healthy smile is to schedule an appointment. Please contact our office by phone or complete the appointment request form below. Our scheduling coordinator will contact you to schedule your appointment. based on your preferences provided.
Are you a new or existing patient?
*
New Patient
Existing Patient
We are happy to see you again!
Please call or text us @ 716-631-9924 and we'd be happy to help.
What is the name of the patient we will be seeing?
*
What is the date of birth for the patient we will be seeing?
*
/
Month
/
Day
Year
Date
Who will be responsible for any financial liability for the patient?
*
What is your relationship to the patient?
*
Self
Parent/Guardian
Spouse
What is the patient's address?
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Which office would the patient prefer to be seen at?
Williamsville
Blasdell
Attica
Warsaw
What sort of treatment is the patient seeking?
*
Metal Braces
Clear Braces
Clear Aligners (i.e. Invisalign or 3M Clarity)
Who does the patient see for general dental concerns (e.g. cleaning, fillings, flouride treatments)?
*
If the patient does not have a current dentist please be aware that we may refer for a cleaning prior to orthodontic treatment.
Does the patient have dental insurance?
*
Yes
No
Upload a copy of the patient's insurance card
Browse Files
Drag and drop files here
Choose a file
Optional
Cancel
of
What insurance does the patient have?
*
What is the subscriber ID# for the patient?
*
If unknown or you don't have an ID card please provide the subscriber's SSN.
How did you hear about us?
*
Family
Friend
Dentist
Insurance
Internet Search
What is the best phone number we can contact you to schedule?
*
Provide full 10 digit number please.
Any Questions/Comments/Concerns?
Please verify that you are human
*
Save
Submit
Should be Empty: