Schedule Your Appointment

Request an appointment online and we'll contact you to confirm your visit

Appointment Request Form

Patient Information

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth

Appointment Details

Preferred Date *

Office closed on weekends

Preferred Time *

Reason for Visit *

Referring Dentist Information

Dentist Name

Practice Name

Insurance Information

Insurance Provider

Leave blank if self-pay

Additional Information

Additional Notes or Questions

This is an emergency
Check this if you're experiencing severe pain or swelling and need immediate care

* Required fields
We will contact you within 24 hours to confirm your appointment

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What to Expect

After submitting this form, we'll call you to confirm your appointment and answer any questions you may have.

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First Visit

Please arrive 15 minutes early to complete paperwork. Bring your insurance card and ID.

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Emergency Care

For immediate assistance, please call us directly at (317) 555-1234. We offer same-day emergency appointments.

Office Hours

Monday - Thursday: 8:00 AM - 5:00 PM

Friday: 8:00 AM - 2:00 PM

Saturday - Sunday: Closed

Emergency appointments available outside regular hours