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Request an Appointment

At Dent Aid Dentistry, we provide the highest quality service to all our patients. Use the form below to request your appointment. Please indicate your preferred date and time. Please note that we will reach out to you first to confirm your appointment or to provide you with an alternative date. You may also call us to request an appointment. Thank you!

Are you an existing patient with our practice?*

YesNo

What is the reason you need a dental visit?*

Let us know what you need so we can make sure you get the best care - even if it's just a checkup!

Urgent Issue
Checkup & Cleaning
Specific Treatment

Are you experiencing any kind of pain?

YesNo

Describe the situation that the doctor should be aware of?*

What is your name?*

What is the best phone number to reach you at?*

What is your email address?*

When would be a good time for our staff to reach you and confirm the appointment?*

Should we contact you via phone or email? Would it be better to call in the morning or afternoon?

Insurance Information

Will you be using insurance?

Yes
No

Using the section below, please upload clear photos of the insurance card both front and back.

Front of insurance card

Back of insurance card

By submitting this form I have read and acknowledged the Privacy policy

Thank you. We will connect with you shortly to confirm your appointment.

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