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Appointment Assistant What’s the reason for your visit?

Emergency

Broken tooth

Tooth pain

Dentures/Implants

Clear aligners

Other/Check up

Need further assistance?
Call 1-800-277-3633

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Parent/Guardian consent is needed for patients under 18 years of age.

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I verify I am the child's legal guarantor.

Additional Patient Information

First Name ^*

Last Name ^*

Date of Birth ^*

Email Address ^*

Mobile Phone Number ^*

Do you have dental insurance?

Appointment Assistant What’s the reason for your visit?