Request Appointment Online

Patient Name*
Patient Birth Date*
Date Format: MM slash DD slash YYYY
Contact Information
Type of Primary Phone*
Primary Phone Number*
Email*
Preferred Appointment Date & Time
Appointment Urgency
- I would like to be seen ASAP
Date
Date Format: MM slash DD slash YYYY
Time of Day

: HH

MM
Location*
Dental Priorities
This form is only for new patients to request an appointment.

Please DO NOT use this form to request dental records.

All dental record requests must be requested by phone from the office where you are a patient.
Emergency Care
- I need prompt emergency care
Dental Needs*
- Dental Exam and Cleaning
- Filling
- Bridge or Crown
- Dentures or Partials
- Dental Implants
- Gum Therapy
- Periodontal Services
- Extraction
- Other
Dental Insurance Company*
We do not accept Access/Avesis, Gateway, UPMC for You, UPMC For Life, Highmark Wholecare, or HMO/DMO dental insurance plans.
Dental Insurance I.D. Number*
Enter 'none' if you have no insurance
Insurance Subscriber Name*
Enter 'none' if you have no insurance
Consent*
I agree with the storage and handling of my data by this website. - Privacy Policy.
Name
This field is for validation purposes and should be left unchanged.

Contact Information