Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.Please complete the following form to request an appointment. Please also note that availability will vary depending on your request. Your appointment will be confirmed by phone by a team member. Thank you!Dental BenefitsNoMedicaidOtherWe’re sorry, but we are unable to accept Medicaid. If you are open to alternate financing options, please proceedName Phone* Email* Preferred LocationPlease SelectMiles City OfficeSidney OfficePreferred Date* MM slash DD slash YYYY Preferred TimeMorningAfternoonEveningNature of VisitCommentsThis field is for validation purposes and should be left unchanged.