Are you a new or existing patient?

What is your name?

What is the best email address for you?

Let's also grab your phone number.

Do you know the tooth number that is bothering you?

Enter the tooth number below, if you don't know it, skip ahead to the next question. 

Do you have dental insurance you'd like to use?

If not, that's okay, go ahead and skip to the next question.

Which dental insurance carrier do you have?

If applicable, if not, please go ahead and skip to the next question. 

Finally, what date works best for your appointment?

We'll do our best to accommodate your selection, and we'll call you shortly to confirm a date and time.