| Internet Express Scheduling for New Patients To schedule a complete new patient examination, necessary x-rays, and an introductory cleaning, just complete the following form and one of our team members will contact you as soon as possible to schedule a convenient time for your first appointment. Please call me to schedule an appointment for a comprehensive new patient examination, necessary x-rays, and an introductory cleaning. Please call me as indicated below: |
| Title & First name |
| Last name |
| Middle Initial |
| Work phone |
| Home phone |
| Cell/Mobile/Other |
| Call Me |
| Best time to call me is |
| Desired Day and time for appointment |
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| Is there a chief complaint or specific problem that you are having with your mouth at this time? |
| Is there anything about your smile that you do not like? |
