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.

    Patient Name *

    Parent Name

    Dentist *

    Phone *

    Type of Appointment

    Preferred Location *


    Preferred Day of the Week

    Main Orthodontic Concern: