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Schedule an Appointment
Please complete this form to request your next dental appointment. We will do our best to accommodate your request and contact you via phone and/or email to confirm your appointment.
Important Note: Your appointment request does NOT guarantee an appointment at the day/ time you requested. Please allow 24 hours to receive a confirmation phone call and/or email from our office.
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Name
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First
Last
Phone Number
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Choose One
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I am a current patient
I am a new patient
Note: As a new patient, please ask your previous dentist to email your most recent x-rays to Dr. Sam at:
[email protected]
Your Preferred Appointment DATE
*
Your Preferred Appointment TIME
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Email
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Type of Appointment or Comments
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Request an Appointment