734-482-1300
The first step towards a beautiful, healthy smile is to schedule an appointment. Please contact our office by phone or complete the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment.
Please do not use this form to cancel or change an existing appointment.
Items in
bold
are required.
Name:
Address:
City:
State/Province:
Zip/Postal:
Phone:
Email:
Are you a current patient?
Yes
No
How did you hear about us?
Best time(s) to call?
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Which office location(s) would you prefer for your appointment?
*
Ypsilanti 1637 S. Huron St.
Preferred day(s) of the week for an appointment?
Any Day
Monday
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Wednesday
Thursday
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Saturday
Preferred time(s) for an appointment?
Any Time
Morning
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Afternoon
Evening
Please describe the nature of your appointment (e.g., consultation, check-up, etc.):
Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.