Request an Appointment

You are a:
 New Patient Current Patient

Your Name

Home Phone:

Office/Cell/Other Phone (required)

Your Email (required)

Referral source (new patients only)

Purpose of Dental Visit (required):

You must select at least one choice. You may select as many as are applicable.

 FREE Invisalign Consultation (by appt only) Bleaching/whitening Bonding Braces Broken or missing teeth Cleaning & check-up Crowns, caps, & fixed bridges DenturesExtraction Examination Fillings Implants Pain Periodontal (gum) therapy or surgery Porcelain laminates/veneers Retainers (fixed or removable) Root canal therapy Second opinion TMJ & bite plates Wisdom teeth X-rays

Please provide more details in the box below:

Your preferred days and times of appointments:

Office hours: Monday - Thursday, 8:00 AM - 4:00 PM & Friday, 8:00 AM - 1:00 PM
(Please give several choices):

Preferred Time of Day:

Preferred Day and/or Dates:

Please note that the last schedule appointment time each day is 3:30 PM

Preferred Method of Contact

 email Home Phone Office/Cell/Other Phone

Best time to call:

We’re transforming lives in Austin, one smile at a time. Contact our dental office today at 512-448-3131 to reserve your appointment with Dr. Van Wicklen, and experience customized care for a truly fantastic smile.