Request an Appointment



The first step toward achieving a beautiful, healthy smile is to schedule an appointment. To schedule an appointment, please complete and submit the request form below.

Please note this form is for requesting an appointment. If you need to cancel or reschedule an existing appointment, or if you require immediate attention, please contact our practice directly.

    Patient Name *

    Parent Name


    Phone *

    Type of Appointment

    Preferred Location *

    Preferred Date *

    Preferred Time *


    Disclaimer: This form sends a secure message to our office. When we reply, it will be in the form of a secure message that will require you to create a password to open. Please check the appropriate box below to indicate if you wish for us to return your reply using a secure email.