Appointment Request Form Please fill in the form below to setup an appointment.Reason for AppointmentPlease provide a reason for your appointment. Details are stored securely and not sent by email.Preferred Date & Times*Please let us know when you would prefer to have your appointment. You may also visit https://www.smilereminder.com/sr/schedule/anon.do?id=5dcc7903e4c00d3d to select a date and time, Our hours are listed on our location page.Patient Type*New patientReturning patientPlease let us know if you are a new or existing patient.Name* First Last Phone*Email* Best Time to be Reached for Confirmation* : HH MM AM PM Insurance Information*Insurance #1- MedicalInsurance #1- VisionInsurance #1- Secondary Please provide your Insurance Information to authorize your visit. For plans that require a Referral please contact your PCP to process prior to your visit. NPI 1366491672CommentsCommentsThis field is for validation purposes and should be left unchanged.