Request an Appointment

All information is private and not used or shared with anyone, as outlined in the HIPPAA guidelines.

    Are you a current or former patient at our office? (required)
    YesNo

    Child's First Name (required)

    Last Name (required)

    Date of Birth (required)

    Parent / Guardian Name (required)

    Email (required)

    Phone (required)

    Preferred Contact

    Preferred Month

    Preferred Time
    AMPM

    Treatment Options
    Regular CheckupFirst Dentist VisitEmergency/UrgentOther

    Do you have Dental Insurance?
    YesNo

    If "yes", who is your Dental Insurance Provider?

    (Our office gladly accepts children with no dental insurance)

    Additional Notes

    [recaptcha]