Contact Us

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 PatientExisting 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?*

MonthDayYear
Date
Who will be responsible for any financial liability for the patient?*
What is your relationship to the patient?*

SelfParent/GuardianSpouse
What is the patient's address?*

Street Address

Street Address Line 2

CityState

Zip Code
Which office would the patient prefer to be seen at?

WilliamsvilleBlasdellAtticaWarsaw
What sort of treatment is the patient seeking?*

Metal BracesClear BracesClear 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?*

YesNo
Upload a copy of the patient's insurance card

Optional
Cancelof
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?*

FamilyFriendDentistInsuranceInternet 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*
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Contact Us

We are happy to see you again!