Appointment Request

Please note that we are a referral based specialty clinic, and we do need to have a referral from your general dentist in order to schedule an appointment, if you are a new patient.  Existing patients, requiring new treatment, should also obtain a referral from their general dentist.

Please do not use this form to cancel or change an existing appointment.

*Items in bold are required.
Are you a current patient?

Preferred day(s) of the week for an appointment?

Preferred time(s) for an appointment?

Please describe the nature of your appointment (e.g., consultation, check-up, etc.):

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.