Requesting
Rescheduling
Canceling
( We
require two business days notice for cancellations.)
Name:
(First and Last name)
E-Mail
Address:
Please make sure emails from our website
address are not blocked by your email spam filters!
Phone
Number:
(Best contact number)
Type
of Appointment:
Cleaning
& Exam with Virginia,
RDH and/or Trevi,
RDH
Dental
Treatment Emergency
(Please describe your needs if requesting treatment or
emergency.)
Please
specify a date after August
4th
if you are requesting a cleaning appointment.
We are on vacation from June 22nd through July 7th and July
16th - July 21st.
Our Office Hours:
Tuesday & Wednesday 8:00am - 6:00pm
Thursday 7:00am - 5:00pm
Friday 7:00am - 4:00pm
We do not work on Mondays, hours on
Tuesday and Wednesday have recently changed.
Current
Appointment :
(if applicable)
Date
Time
:
am pm
Requested
Appointment:
Date
Time
:
am pm
Morning and evening appointments are the most popular, please
specify all your available days and times if your first choice
is not available. If
you do not need a specific date and time, tell us what is convenient for
you, i.e. days of
the week, am or pm and range
of dates.
Called
for Cancellation:
Yes
No
(By checking yes, you will be called when openings become
available.)
Other
Requests/
Days of the Week and Times Preferred for Cancellations: