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Appointment, Consultation, and Information Request Form

Patient Information

(All information is strictly confidential and will not be shared)

I am an existing patient

First Name

Preferred Name

Last Name

City

State

Zip Code

Cell Phone Other Phone E-mail Address

New Patient Appointment Options

To schedule a NEW PATIENT appointment
To schedule a consultation or treatment with a specialist
- Orthodontist - Invisalign
- Oral Surgeon - Extractions, Biopsy, Miscellaneous Surgery
- Endodontist - Root Canal
- Periodontist - Gum Treatments, Tooth or Teeth Implants
- Dental Implants
To receive more Information
- Talk to a Doctor
- Ask questions about treatments or services
- Receive information about the practice

Existing Patient Appointment Options

To schedule a CLEANING AND CHECKUP (RECALL) appointment for me or a family member.
To CHECK ON A PROBLEM in my mouth.
To schedule a consultation or treatment with a specialist
- Orthodontist - Invisalign
- Oral Surgeon - Extractions, Biopsy, Miscellaneous Surgery
- Endodontist - Root Canal
- Periodontist - Gum Treatments, Tooth or Teeth Implants
- Dental Implants
To discuss my account
To speak to the doctor

Online Dental Forms Instructions
Appointment & Information Request
Doctor's Referral
Patient Forms

4944 Windplay Drive, Suite 300, El Dorado Hills, CA 95762 | (916) 941-2333

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