Request an Appointment:

The first step toward achieving a healthy smile is to schedule an appointment with us. To schedule an appointment, please complete and submit the form below. Our scheduling team will contact you as soon as possible to confirm your appointment. Please note, this form is for requesting an appointment. If you need to change an existing appointment, or if you require immediate attention, please contact our practice directly.

Patient's Name

Child's First Name *

Last Name *

Child's Age (Yrs) *

Parent/Guardian Name

Parent/Guardian First Name *

Last Name *

Phone *

Email

Do you have a referral (note: a referral is not necessary to see us)YesNo

If applicable, please state your referrer details (name of clinician, clinic name, etc.)

Your Message (please list any concerns you have about your child's teeth) *

Add an attachment (i.e. referral letter, previous x-rays)

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Please indicate your preferred days and times for an appointment. Please note, we like to schedule younger patients earlier in the day since they tend to be more alert and cooperative

MondayTuesdayWednesdayThursdayFridayAMPM

We will connect your request with one of our clinicians and reach out to schedule an appointment

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