Your Name (required) Your Child’s Name (required) Are you a new patient? YesNo Your Email (required) Address Your Phone Preferred Days Convenient Times Date of Birth Type of Insurance Have you ever been seen by a dentist? YesNo If yes, when was your last cleaning? If yes, where was your last cleaning performed? How did you hear about our practice? —AdFriendGoogle SearchStaff MemberYellow PagesOther How did you find our website? —AdFriendGoogle SearchStaff MemberYellow PagesOther Your Message We are providing this Contact Us form as a convenience but your message to us should not imply the creation of a doctor-patient relationship (which only happens when you come to our office for a visit). We therefore ask that you not include personal health information in your message. Please call us if you’d like to send us personal information so that we can make sure it’s handled securely.