Request An Appointment

I am*

an existing patient
a new patient

How did you hear about us?*

Name*

First Last

Date of Birth*

Reason for Visit*

Note: you must be current with your dental cleanings before getting whitening treatment. If you are due for a cleaning we will schedule that first: depending on the schedule, we may be able to accommodate a whitening treatment the same day. Otherwise we may need to schedule a subsequent appointment.

If "Other" please explain:

Consultation Type

Which Location Do You Prefer?*

Do you have a preferred doctor?

Leave blank for no preference.

Do you have dental insurance?

Yes
No (self-pay)

Which day(s) of the week/time do you prefer for your appointment(s)*

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
First Available/No preference

Preferred Time(s) for your appointment*

Morning
Afternoon
Evening (5pm or later)
First Available/No Preference

Contact Information

Email*

Phone*

Contact Preference*

Email
Phone

Is there any other information you'd like to add?

Captcha

Phone

This field is for validation purposes and should be left unchanged.

Find an Office

Call us Today!

Office Hours

Appointments

Contact Information