Request an INITIAL appointment
Please complete the following information. Our forms are HIPAA-compliant. All information is considered to be sensitive and important and will not, under any circumstances, be sold or distributed without your express, written permission.
For more information on how your information can be used, please see "Privacy Policy" and "HIPAA Compliance" on our website.
A member of our team will contact you to discuss you concerns. Please allow 10-15 minutes for the phone call as we would like to fully understand your reasons for becoming a patient. This information will be shared with our doctors prior to your initial evaluation.
Email address *
Patient Name (First and Last) *
Patient DOB *
Your Name (First and Last) *
Preferred Contact # *
Dentist Name *
Would you like for us to contact your dentist prior to your initial evaluation with our doctors?
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Tell us a little about your concerns. *
What time would you like for us to call you? *
Which of our locations best fits your needs?
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How did you hear about us?
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This form was created inside of Classic City Orthodontics, PC.