Dental Symphony - Patient Page

Dark Mode:

Welcome to our Appointment Request portal

FOR NEW PATIENTS ONLY. If you would like to request a new patient appointment for your child, you may call our office or fill out the appointment request form below. One of our new patient coordinators will be happy to contact you to schedule an appointment!
***Please note: We can only accept Medicaid for children who are diagnosed with a special need.
*Please note: This form is for NEW PATIENTS only. This form is not to reschedule or cancel an appointment. Please call our office to reschedule or cancel an appointment. Thank you!

Location Information

Please select the location you are submitting to:

Patient Information

*First name:

*Last name:

*Date of birth:

*Is this a New or Returning patient?

New

Returning

Parent/Guardian name (if applicable)

*Contact phone:

*Contact email:

Best method to contact:

Preferred day(s) of the week for an appointment?

Any Day

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Preferred time(s) for an appointment? Any Time

Morning

Noon

Afternoon

Evening

*Reason for appointment:

Dental Insurance provider

Please note this is only an appointment request form. A staff member will reach out to you to confirm a date and time.

Welcome to our Appointment Request portal

Location Information

Patient Information

Thank you for requesting an appointment. We will reach out soon to confirm the details and date/time of the appointment.