PATIENT APPOINTMENT SCHEDULER * Indicates field is required Active Patient      Inactive Patient      New Patient Name: * Home Phone: Office Phone: Email: * City: State: Zipcode (postal code): * Country: * Referral Source: (new patients only): PURPOSE OF DENTAL VISIT (you may select more than one choice): Bleaching/whitening Bonding Braces Broken or missing teeth Cleaning & check-up Cosmetic dentistry Crowns, caps & fixed bridges Dentures Diagnosis of soft tissue lesions Emergency Examination Extraction Fillings FREE initial consultation for new      patients Implants Oral Microbiology Oral Surgery Pain Periodontal (gum) therapy      or surgery Porcelain laminates/veneers Post and core Reevaluation Retainers (fixed or removable) Root canal therapy Root planning & scaling     (deep cleaning) Sculpting (reshaping teeth) Temporary filling or caps TMJ & bite plates Wisdom teeth X-rays Please provide more details in the box below: PREFERRED DAYS AND TIMES OF APPOINTMENTS Office hours: Monday - Friday, 9:00 am - 6:00 pm (last appointment) (Please give several choices): Preferred Time of Day: * Preferred Days and/or Dates: * Preferred Provider (if any): APPOINTMENT CONFIRMATION (Preferred method to receive your appointment confirmation) : * One appointment confirmation method is required Home Phone      Office Phone      Email If you send this Patient Appointment Scheduler to us during the week between 9:00 am and 5:00 pm you will receive your confirmation by the end of the day. You will receive your appointment confirmation on the next business day if you contact us after business hours.