Appointments

FOR NEW PATIENTS:

Just complete the following form and one of our team members will contact you as soon as possible to schedule a convenient time for your first appointment.

Please provide the following contact information:

1. Firstname
2. Lastname
3. Middle initial
4. Street address
5. Address(cont.)
6. City
7. State/Province
8. Zip/Postal code
9. Work phone
10. Home phone
11. Call me at
12. Best time
13. How did you hear about us?
14. FAX
15. E-mail
16. Referred by

 

RETURNING PATIENTS:

Please call me to schedule an appointment for a comprehensive cleaning appointment with your hygienist and an examination of my teeth and gums. Please call me as indicated below:

Please provide the following contact information:

1. Firstname
2. Lastname
3. Middle initial
4. Work phone
5. Home phone
6. Call me at
7. Best time
8. E-mail