Date of Birth:

Are you... *

Current patient

New patient

What can we schedule you for? *

Select all that apply

Cleaning / Exam

Whitening

Toothache

Broken tooth

Consultation

Other

Please tell us the details

What Days/Times of the week do you prefer?

Email Address *

Do you have insurance?

Yes

No

Who is your dental insurance thru?

Policy Holder Name and DOB

Policy Holder's Employer:

Insurance ID#:

Insurance Group #:

Which doctor would you like to see? *

Please select one

DR. LAKEBRINK

DR. MITTS

EITHER DOCTOR

If new patient, how were you referred to our office? (if by another patient, please list the patients name)

Let's get you on the books!