Appointment Request -

Are you an existing patient or a new patient?

Existing Patient
New Patient

Are you coming in for a cleaning/check up or is this an emergency visit?

Cleaning/Checkup
Emergency Visit

If you are experiencing a dental emergency- what is the emergency – please give details

Name

First

Last

Date of Birth

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Do you have recent X-rays at another office?

Yes
No

subscriber the this

*Please have them forwarded to info@dentalartsofplainville.com in JPEG format as single images with dates they were taken. As soon as we receive them, we will reach out to you to schedule.

Do you have dental insurance?

Yes
No

Please tell us your plan, your id#, subscriber and subscriber DOB. We need this information prior to your visit to get a breakdown and history of your benefits.

What is your availability, how flexible are you with the schedule?

What is the reason for appointment (checkup and cleaning/discomfort)?

Were you seen recently?

Yes
No

What is the treatment for which you are requesting an appt?

If you are experiencing dental emergency- what is the emergency – please give details

What is your availability, how flexible are you with the schedule?

Are there any changes with your dental insurance?

Yes
No

Please provide all details with your dental insurance change.