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Appointment Request

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 confirm your appointment.

Please do not use this form to cancel or change an existing appointment.

Within the comment section BELOW, please provide your INSURANCE information and type of plan (i.e. PPO, DHMO, and MEDICAID). We unfortunately, do NOT accept DHMO nor MEDICAID, however, we would still be happy to see you as an uninsured patient within our practice.

*Items in bold are required.
Are you a current patient?

Preferred day(s) of the week for an appointment?

Preferred time(s) for an appointment?

Please describe the nature of your appointment (e.g., consultation, check-up, etc.):

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information. 


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