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PATIENT APPOINTMENT SCHEDULER
* Indicates field is required
Active Patient Inactive Patient New Patient
Name: *
Home Phone:
Office Phone:
Email: *
City:
State:
Zipcode (postal code): *
Country: *
Referral Source: (new patients only):
PURPOSE OF DENTAL VISIT (you may select more than one choice):
Bleaching/whitening	Bonding
Braces	Broken or missing teeth
Cleaning & check-up	Cosmetic dentistry
Crowns, caps & fixed bridges	Dentures
Diagnosis of soft tissue lesions	Emergency
Examination	Extraction
Fillings
Implants	Oral Microbiology
Oral Surgery	Pain
Periodontal (gum) therapy or surgery	Porcelain laminates/veneers
Post and core	Reevaluation
Retainers (fixed or removable)	Root canal therapy
Root planning & scaling (deep cleaning)	Sculpting (reshaping teeth)
Temporary filling or caps	TMJ & bite plates
Wisdom teeth	X-rays
Please provide more details in the box below:
PREFERRED DAYS AND TIMES OF APPOINTMENTS Office hours: Monday - Friday, 9:00 am - 6:00 pm (last appointment) (Please give several choices):
Preferred Time of Day: *
Preferred Days and/or Dates: *
Preferred Provider (if any):
APPOINTMENT CONFIRMATION (Preferred method to receive your appointment confirmation) :
* One appointment confirmation method is required Home Phone Office Phone Email
If you send this Patient Appointment Scheduler to us during the week between 9:00 am and 5:00 pm you will receive your confirmation by the end of the day. You will receive your appointment confirmation on the next business day if you contact us after business hours.

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