Appointment Booking

Please fill out this form to schedule an appointment with our office. We will contact you with further instructions. If you are paying a booking fee, please follow our secure checkout

Appointment Day*

Please select a day that you are available for the appointment. Please consider the time we allow for appointments to allow in your schedule

Emergency exams are 30 min

New patient exams are 1.5 hrs

Consultations are typically 15min

Time*

We reserve appointments for new patients Monday through Thursday at 9am, 11:30am, and 3:30pm.

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Select a location*

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First Name*

Date of Birth*

Email*

Cell Phone Number*

Address, State, Zip Code*

Insurance Information

Subscriber First Name (if different from patient)*

Subscriber Last Name (if different from patient)*

Subscriber Date of Birth*

Subscriber Relationship to Patient*

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Please upload a picture of your

dental and medical cards FRONT and BACK
x-rays if you have any
records from your previous providers

Drag and drop files here or

Assignment of benefits*

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1. Chief Complaint of Conditions*

Chief Complaint-Tell us how we can help you? What dental concerns do you have? If you just want a routine cleaning and exam, please state so.

If you have any dental problems, please fill out the questions below.

9. Progression of the Condition from Onset to Now

3. State things that WORKED for your symptoms?

4. List what Did NOT help your symptoms?

8. Onset-When, how did it start-History of Illness

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