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765-651-9500
2017 South Western Avenue, Marion, IN 46953
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General Dentistry
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Emergency Dental Care
Extractions
Gentle, Professional Cleanings
Mouth Guards
Night Guards
Oral Cancer Screening
Periodontal / Gum Disease Treatment
Root Canal Therapy
Cosmetic Dentistry
Dental Crowns
Traditional Braces
White Fillings
Zoom! In-Office Teeth Whitening
Restorative Dentistry
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Comfort Dentistry
Nitrous Oxide Comfort Dentistry
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Home
»
Patient Resources
Make an Appointment
Solutions & Services
General Dentistry
Comprehensive Exams
Digital X-Ray
Emergency Dental Care
Extractions
Gentle, Professional Cleanings
Mouth Guards
Night Guards
Oral Cancer Screening
Periodontal / Gum Disease Treatment
Root Canal Therapy
Cosmetic Dentistry
Dental Crowns
Traditional Braces
White Fillings
Zoom! In-Office Teeth Whitening
Restorative Dentistry
Dentures
Comfort Dentistry
Nitrous Oxide Comfort Dentistry
Make an Appointment
First Name
*
Last Name
*
Phone Number
*
Email Address
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Verify Email Address
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Date of Birth
*
Date
E.g., 08/18/2017
Are you a new patient?
*
Yes
No
How did you hear of us?
- SELECT Marketing Type -
Patient Referral
Website/GoogleSearch/Etc.
1800 Dentist (per referral)
Location/Drive By/Sign
Daily Deal/Groupon
Insurance Company
Yellow Pages Print
Other Marketing
Is your family, friend or coworker a current patient? We’d love to have their name so we can thank them for referring you to us
How did you hear about our office?
Reason for your visit
*
Dental Cleaning
Dental Emergency
Dentures or Implants
Cosmetic - teeth whitening, veneers, bonding, etc.
Filling
Crown
Extraction
Dental Consultation (Second opinion or Invisalign)
Other
Please provide a brief explanation of the reason for your visit
Are you experiencing pain, swelling, or bleeding?
*
Yes
No
Where is the problem area located?
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Rate pain (1-10)
*
1
2
3
4
5
6
7
8
9
10
On a scale of 1 to 10, please rate your level of pain with 1 being the least and 10 being the most.
Do you have insurance?
*
Yes
No
Who is your dental insurance provider
Best day(s) for your appointment
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Monday
Tuesday
Wednesday
Thursday
Best time?
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Morning
Afternoon
No Preference
Specific Time
If a specific time is necessary, please indicate the time.
How do you prefer we contact you?
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Email
Phone
Note: we do not accept appointment cancellations via email.
Do you require any special accommodations?
*
Yes
No
Accommodations required
In order to request an appointment you must be 13 years of age or older.
*
Yes, I am 13 years of age or older
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Office Hours
Monday:
8:00 AM - 5:00 PM
Tuesday:
8:00 AM - 5:00 PM
Wednesday:
9:00 AM - 5:00 PM
Thursday:
8:00 AM - 5:00 PM
