Intake form

Help us serve you better

Name *

Email address *

Phone number

Reason for visit

Please select at least one option.

Routine check-up

Dental cleaning

Tooth extraction

Fillings

Braces consultation

Cosmetic dentistry

Root canal

Emergency care

Preferred appointment time

Do you have any dental insurance?

If yes, please specify

Additional questions or comments

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DentAlert Dental Clinic