Appointment Request Are you an existing patient or a new patient? Existing Patient New Patient Are you coming in for a cleaning/check up or is this an emergency visit? Cleaning/Checkup Emergency Visit If you are experiencing a dental emergency- what is the emergency - please give details*Name* First Last Date of Birth* MM slash DD slash YYYY Phone*Address. Please include Town and Zip Code*Email* Do you have recent X-rays at another office?* Yes No *Please have them forwarded to arossis513@yahoo.com in JPEG format as single images with dates they were taken. As soon as we receive them, we will reach out to you to schedule.Do you have dental insurance?* Yes No Please tell us your plan, your id#, subscriber and subscriber DOB. We need this information prior to your visit to get a breakdown and history of your benefits.*What is your availability, how flexible are you with the schedule?*What is the reason for appointment (checkup and cleaning/discomfort)?*Were you seen recently?* Yes No What is the treatment for which you are requesting an appt?*If you are experiencing dental emergency- what is the emergency - please give detailsWhat is your availability, how flexible are you with the schedule?*Are there any changes with your dental insurance?* Yes No Please provide all details with your dental insurance change.*How did you hear of us?*
