Patient Appointment Scheduler

* Indicates field is required

Active Patient Inactive Patient New Patient

Select dental surgery area *
Name: *
Home Phone:
Office Hours Contact Phone: *
Email: *
City:
State:
Zipcode (postal code):*
Country: *
Referral Source: (new patients only):

PURPOSE OF DENTAL VISIT (you may select more than one choice): Click Me to Edit Bleaching/whitening Bonding Braces Broken or missing teeth Cleaning & check-up Cosmetic dentistry Crowns, caps & fixed bridges Dentures Diagnosis of soft tissue lesions Emergency Examination Extraction Fillings Implants Oral Microbiology Oral Surgery Pain Periodontal (gum) therapy or surgery Porcelain laminates/veneers Post and core Re-evaluation Retainers (fixed or removable) Root canal therapy Root planning & scaling (deep cleaning) Sculpting (reshaping teeth) Temporary filling or caps TMJ & bite plates Wisdom teeth X-rays

Please provide more details in the box below:


PREFERRED DAYS AND TIMES OF APPOINTMENTS Office hours: Monday - Friday, 8:00 am - 5:00 pm (last appointment). Saturday appointments (by Special arrangement from 8 to 12). Please give several choices:

Preferred Time of Day: *
Preferred Days and/or Dates: *
Preferred Provider (if any):

APPOINTMENT CONFIRMATION (Preferred method to receive your appointment confirmation) : * One appointment confirmation method is required
Home Phone Office Phone Email

If you send this Patient Appointment Scheduler to us during the week between 9:00 am and 6:00 pm you will receive your confirmation by the end of the day. You will receive your appointment confirmation within 24 hours.

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We are registered with the Health Professionals Council of South Africa as well as the General Dental Council in the United Kingdom and also affiliated to the South African Dental Association (SADA)