** Pause on New Patient Registrations. Please click here for more details. Dental Appointment Request Form First Name*Last Name*Email*Cell Phone*Tel. HomeAddress*City*ZIP Code*Date of Birth*Gender*MaleFemaleEthnicity*HispanicNon-HispanicRace*WhiteBlackAsian/PIAm Indian/ Alaskan Native2 or more racesOtherAre you a returning patient?*YesAppointment Type*CleaningExtractionsFillingsDo you presently have health insurance*YesNoReason for Visit*Referral Source*ORMCAdvent HealthHealthlinkChristian SharingPatient in the practiceWord of mouthBueno PharmacyOtherRemarks-.*By submitting the request, I affirm that I don't have any type of insurance and my last 30 days gross household income is less than 300% below the federal poverty line.Urgency? This appointment is urgent. Add me to the waiting list. If available, I can come within 24 hours notice.YesNoSubmit Error occured. Please confirm your data and submit again:
