Request an Appointment

The first step toward achieving a beautiful, healthy smile is to schedule an appointment. To schedule an appointment, please complete and submit the request form below. The initial consultation for your child is complimentary.

Please note this form is for requesting an appointment. If you need to cancel or reschedule an existing appointment, or if you require immediate attention, please contact our practice directly.

*We’re saddened to hear about the closing of Southern Tier Orthodontics and the impact it is having on families in our community. We appreciate your patience as we work through the phone calls, texts and website requests. We are hoping to accommodate those we are able to help.

    Patient Name *

    Parent Name

    Dentist Name *

    Email *

    Responsible Party Phone Number

    Type of Appointment

    Preferred Location

    Preferred Day of the Week

    Main Orthodontic Concern