Appointment Request

The first step towards a beautiful, healthy smile is to schedule an appointment. Please contact our office by phone at (707) 443-1390 or complete the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment.

Eureka Office

707 I St.

Eureka, California 95501

Office Hours:
Monday, Tuesday, Thursday & Friday: 8:30am – 5:00pm

Please do not use this form to cancel or change an existing appointment.

Patient Information

Name

Phone

Are you a current patient?YesNo

How did you hear about us?

Patient Availability

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

Preferred time(s) for an appointment? Any TimeMorningAfternoon

Reason For Visit

Please describe the nature of your appointment?

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.