Appointment Request

(559) 840-4330

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(559) 840-4330

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 on line or print it and bring it in with you. Our Scheduler will contact you to confirm your appointment. Do you prefer email or cell phone?

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

*Items in bold are required.

Name: Email: Phone:

Are you a current patient? Yes
No

How did you hear about us?

Which office location(s) would you prefer for your appointment?

Clovis 1795 Herndon Ave

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

Any DayMondayTuesdayWednesdayThursdayFridaySaturday

Preferred time(s) for an appointment?

Any TimeMorningNoonAfternoonEvening

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

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

Please also fill out our Patient Information Form

Download printable version

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