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Schedule an Appointment
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8
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HIPAA
Compliance
1
Name
*
This field is required.
First Name
Last Name
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2
Email
*
This field is required.
example@example.com
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3
Cell Phone Number
*
This field is required.
Area Code
Phone Number
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4
Are you a New or Existing Patient?
New Patient
Existing Patient
New Patient
Existing Patient
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5
What would you like to schedule an appointment for?
*
This field is required.
New Patient Exam and Cleaning
Recare Exam and Cleaning
I am having an emergency!
Consultation with the Dentist
Zoom in-office Whitening session
Consultation with the Dentist
Other
New Patient Exam and Cleaning
Recare Exam and Cleaning
I am having an emergency!
Consultation with the Dentist
Zoom in-office Whitening session
Consultation with the Dentist
Other
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6
Please describe your emergency in detail
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7
Please describe the reason for your appointment?
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8
Do You have dental insurance?
*
This field is required.
Yes
No
Yes
No
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9
Preferred day of the week
Pick one or several days
Monday
Tuesday
Thursday
Friday
Saturday
Any day
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10
Preferred time of day
Morning
Afternoon
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11
What type of dental insurance do you have?
*
This field is required.
Delta
Aetna
Metlife
Cigna
United Healthcare HMO
Blue Cross Blue Shield
Guardian
United Healthcare PPO
No dental insurance
Other
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