PA Department of Health Ruling Regarding Dental Appointments

Request Appointment Online

  • Date Format: MM slash DD slash YYYY
  • Contact Information

  • Preferred Appointment Date & Time

  • Date Format: MM slash DD slash YYYY
  • :
  • 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.
  • 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.
  • Enter 'none' if you have no insurance
  • Enter 'none' if you have no insurance
  • This field is for validation purposes and should be left unchanged.