Appointment Request

The first step towards a beautiful, healthy smile is to schedule an
appointment. Please contact our office by phone or complete the
appointment request form below. Our scheduling coordinator will contact
you to confirm your appointment.

We are open:
• Monday –Tuesday – Thursday from 930 a.m. – 8 p.m.
• Wed 930 a.m. – 6 p.m. Friday 930 a.m. – 4 p.m.
• Saturday from 9 a.m. – 6 p.m.
• Closed on Sundays emergency only 516-313-6735

Please do not use this form to cancel or change an existing appointment.

*Items in bold are required.

Name:
 
Address:
City:
State/Province:
Zip/Postal:
Email:
Phone:
 
Are you a current patient?


Best time(s) to call?




Preferred
day(s) of the week for an appointment?








Preferred
time(s) for an appointment?








Please describe the nature of your
appointment (e.g., consultation, check-up, etc.):





Note:
Messages sent using this form are not considered private. Please
contact our office by telephone if sending highly confidential or
private information.