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Appointment Request
Appointment request form
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Name
*
Email
*
Please tell us who you are:
*
New Patient
Existing or Returning Patient
Family Member of Existing Patient
Type of appointment requested
*
— Select Choice —
Dental Exam & Cleaning
Cleaning only
Planned Treatment within the last 6 months
Emergency Treatment/Pain
Consultation
Preferred day(s) and time(s) for your appointment – you can select more than one
*
Anytime
Monday AM
Monday PM
Tuesday AM
Tuesday PM
Wednesday AM
Wednesday PM
Thursday AM
Thursday PM
Friday AM
Friday PM
This form uses email, please NO confidential health or financial information. Please call us at 306-664-5005 if sharing sensitive info.
*
Please include your phone number in your message, and we will contact you as soon as we can during open hours. You are important to us! IF you have not had a return call – there might be a website glitch with our email forwarding. Please call 306-664-5005
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