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.

Policy Holder Name(If different from patient)

Policy Holder Date of Birth(If different from patient)

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