Request An Appointment

Let’s Get You Scheduled!

If you are a new or established patient and need to schedule an appointment with us, please fill out the following information.

• Please note: Consultations are scheduled in the afternoons Monday-Thursday from 1:30pm – 4pm.
• Using this form will secure you the first available appointment.
• A member of our staff will call you within 48 hours to confirm the date of your appointment.
• To expedite the scheduling process, please fill out your paperwork ahead of time here :  Patient Registration.

 

 

Full Name *

Date of Birth *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Email Address *

Phone Number *

Self-Pay

Self PaySelect if Self-Pay

Patient Status *

New PatientReturning Patient

Dental Insurance Carrier *

Dental Insurance Card *

Drag and Drop (or) Choose Files

Upload Front and Back image of your insurance card.

Referring Doctor

Choose an Office *Select locationSuntreeMelbourneFirst Available

Choose Provider *Select ProviderDr. SchmidDr. KimDr. BanachowksiFirst Available

Reason For Visit

Verify the following:

Completed Patient RegistrationText Notifications Ok

Request To Book