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

How were you referred to our office? *

I'm a current patient

Internet

Another patient of the office

Other

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

Let's get you on the books!