APPOINTMENT REQUEST

APPOINTMENT

APPOINTMENT REQUEST

The first step toward achieving a beautiful, healthy smile is to schedule a consultation. Please use the Online Booking link OR complete the Consultation Request form below and our scheduling coordinator will contact you to confirm your appointment

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.

Looking to Have Your Existing Retainers Checked or Repaired?

Please do not use this link to book an appointment for retainer checks or repairs. Instead, please complete our Appointment Request Form, and our team will contact you to arrange an appointment.

Schedule An Initial Orthodontic Assessment

Appointment Request Form

Unable to find an appointment that works best with your schedule? Please complete the appointment request form and a member of our team will reach out to you

Full Name of Patient

Your Phone Number

Name of Responsible Party (If Patient Under 18 Years of Age)

Your Email Address

Preferred Office Location

How Did You Hear About Us

Seeking Which Services

Is the patient in active orthodontic treatment?

Yes No

Attach X-Ray

Date of X-Ray

Attach photo of insurance card to check coverage

Comment

APPOINTMENT REQUEST

APPOINTMENT