Name *

First Name

Last Name

Phone *

(###)

###

####

I am a

Current Patient

New Patient

The area of my mouth that I need an appointment for is *

Upper Right

Lower Right

Upper Left

Lower Left

I prefer to see: (select all that apply) *

Dr. Lakebrink

Dr. Mitts

Either

Do you have dental insurance? *

YES

NO

Do you currently have or have had the Coronavirus? *

YES

NO

Do you currently work outside of your home? *

YES

NO

Are you currently experiencing any type of illness including but not limited to fever, shortness of breath, or dry coughing? *

YES

NO

Have you been out of the state within the last 2 weeks? *

YES

NO