Affordable Dentistry and Orthodontics

Appointments

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New Appointment Scheduler

Please use this form to contact our office.  You may enter your desired appointment date and time and we will do our best to accommodate your wishes. 

Please fill in all the required information before pressing the Enter or Return key.

If this is your first visit with us, please take the time to review our policies.  If you are new to our practice and would like to save time you may print out the new patient information forms.  Fill them out and bring them with you to your first appointment.  These forms are in Microsoft Word (.doc) format. 

Please provide the following contact information:

Prefix
Patient First Name
Patient Last Name
Contact Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Home Phone  
Work Phone
 Cell Phone  
E-mail
Date of Birth

Which days of the week would you prefer:

Monday Tuesday Wednesday 
Thursday  Friday Saturday

What time of day would you prefer?

Early Morning       Late Morning
Early Afternoon    Late Afternoon

You may also request a specific date:

-- mm/dd/yy

How may we contact you for your appointment?

Home Phone Cell Phone EMail                      Work Phone  US Mail      Pony Express 

Is this your first visit to our office?

Yes No

What is the purpose of this visit?

How did you hear about our office?

Do you have Insurance?

Yes No

Comments / Suggestions? (What is the best time of day to contact you, if necessary?)

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