Date of Birth:

Please tell us the details

What Days/Times of the week do you prefer?

Email Address

Who is your dental insurance through?

Policy Holder Name and DOB

(If you're a new patient, we will need your SS# as well to be able to retrieve your insurance benefits, feel free to list that here on our secure website or call the office to give them that information. 816.792.4455)

Policy Holder's Employer:

Insurance ID#:

Insurance Group #:

If you were referred by another patient, please list the name of who referred you.

Let's get you on the books!