Comprehensive Dental Care

Request an Appointment

First Name		Middle Initial
Last Name
Date of Birth
Email
Daytime Phone with Area Code	-

Please choose two appointment dates in order of preference:

First choice:

Second choice:

What time of day would you prefer? (please check one)

Morning Afternoon Either

Have you ever been a patient with Comprehensive Dental Care before? yes no

If so, approximately when:

Reason for your visit and/or additional information that you wish to provide us. Please be detailed and specific.

How would you like us to confirm your appointment request?

Telephone - preferred and fastest method of confirmation (be sure that you filled in the "phone number" field at the beginning of this form)
E-mail (be sure that you provided an email address at the beginning of this form)

Before submitting this appointment request, please re-read your entries to ensure that your information is accurate.

Office hours: Monday through Thursday 8 a. m. - 4 p. m.