University Pediatric Dentistry

You are here:

Request An Appointment

Name of individual requesting this appointment:*

Phone number for individual requesting this appointment:

Patient Name:*

Patient DOB:*

Parent/Guardian Name:

Phone number for parent/guardian:

Alternate phone number for parent/guardian:

Email address for parent/guardian:

Reason for Visit:*

Preferred Day of Week of Appointment:

Preferred Time of Appointment:

Comments (Please indicate Preferred Office Site):

**This is not for urgent appointments. Please call 911 for medical emergencies or 688-7712 for appointments requiring more immediate attention.

If you are referring a patient for Oral Surgery, please make sure that the proper records are sent to our 1100 Main Street location attn: Oral Surgery.

The information you submit is used only for the purpose of making the appointments you request. University Pediatric Dentistry takes reasonable measures to secure your personal information from unauthorized access, use or disclosure.