ONLINE APPOINTMENT SCHEDULER  Current Patient                       New Patient   *Name:    Home Phone:    Office Phone:   *Email:    Referral Source:  (new patients only) PURPOSE OF DENTAL VISIT: *(you must select at least once choice, you may select as many as are applicable)  FREE Invisalign Consultation (by appointment only)  Bleaching/whitening  Bonding  Braces  Broken or missing teeth  Cleaning & check-up  Dentures  Crowns, caps & fixed bridges  Extraction  Examination  Pain  Implants  Porcelain laminates/veneers  Periodontal (gum) therapy         or surgery  Root canal therapy  Retainers (fixed or removable)  Second opinion  TMJ & bite plates  X-rays  Wisdom teeth  Fillings  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 (Please give several choices):  *Preferred Time of Day:  *Preferred Days and/or Dates: * field is required Please note that the last scheduled appointment time each day is 3:30pm APPOINTMENT CONFIRMATION: *(Preferred method to receive your appointment confirmation) One appointment confirmation method is required  Home Phone (best time to call)     Office Phone (best time to call)