accessibility ACCESSIBILITY

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 staff will contact you to confirm your appointment date and time.

For the fastest appointment scheduling, please call our office directly at 928-282-1282



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



Items in bold are required.
Name:  
Address:
City:
State/Province:
Zip/Postal:
Phone:
Email:
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.