Appointment Request

Your Information

First and Last Name:


Street Address:

Apt #:

City:

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Zip/Postal Code:


Work Phone:

Home Phone:


Patient Information

Patient Name:

Age:

Gender:


Appointment Information

Preferred Appointment Date:

MM/DD/YY

Choose a Time:

If this date is not available, choose a preferred day of the week
(check all that apply):




Reason for Appointment:



Children in pre-school and elementary grades are usually seen in the morning. Late afternoon appointments are reserved for middle and high school age patients.


Comments

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Our Services

  • Preventive care (routine exams and cleanings)
  • Mercury-free tooth colored fillings
  • Crowns (white zirconia or stainless steel crowns)
  • Digital x-rays for less radiation
  • Intra-oral cameras
  • Nitrous Oxide
  • Conscious oral sedation
  • In-office IV sedation
  • Treatment in the hospital setting

We are in-network providers for most dental PPO insurance plans and will be happy to help you maximize your benefits. Please contact us with your insurance information and we will provide you with more information.

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