First Name:

Last Name:

Work Phone:

Home Phone:

Cell Phone:

E-mail:

Your first appointment with us will allow us to gather information about you, your health and dental status, and give us the time to explain your dental needs and discuss your dental goals. Just like an architect wouldn’t start constructing a building without knowing what the client’s needs are, or what the building is to be used for, we must have our “blueprints” before we can begin your treatment. We are extremely thorough at this stage, so allow yourself about 1 1/2 hours of uninterrupted time for this, your most important appointment.

Preferred Times:
(Please select a time which would be most convenient for you)

Morning Lunch Afternoon Evening AnyTime

Preferred days:

Monday Tuesday Wednesday
Thursday Friday Saturday
Any day is OK

We will contact you by phone between 8:30am and 8:00pm to arrange an appointment. What is the best number to reach you at this time?

Please Select One:

Work Home Cell Phone

Special comments: