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Patient's birthdate, for positive identification (required)
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Month
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Day
Year
Email address, OR daytime phone number (your choice), in case we need to contact you
What is the purpose of this appointment?
Cleaning and examination
Emergency (tooth ache)
Cosmetic procedure
Second opinion
Other - explain below
How soon would you like to come in?
Whenever you have time available
As soon as possible
Next week
In two weeks
Do you prefer a particular day?
Any day
Monday
Tuesday
Wednesday
Thursday
Friday
Second choice of days
Any day
Monday
Tuesday
Wednesday
Thursday
Friday
Do you prefer a particular time?
Any day
Early morning
Late morning
Mid-day
Early Afternoon
Early Afternoon
Second choice of times
Any day
Early morning
Late morning
Mid-day
Early Afternoon
Early Afternoon
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