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
Emergency Care
- I need prompt emergency care
Dental Priorities*
Indicate the reason for your dental appointment
Dental Insurance Company*
Enter 'none' if you have no insurance. We accept most, but not all insurance plans. We do not accept Avesis, Gateway, UPMC For You Dental Coverage or HMO 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
Comments
This field is for validation purposes and should be left unchanged.

Contact Information