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Patient Information

Contact Information

Is this your first Orthodontic consultation?:

Have you visited a dentist in the last year?:

Do you have dental insurance?:

If yes, what is the name of your insurance provider?:

What type of treatment are you most interested in?:

If you would like to schedule an examination please use this form. We will be in contact with you as soon as possible to schedule a convenient appointment.

Please use this form if you have any questions or concerns. We monitor our appointment requests several times a day and will usually reply within one business day during open hours.

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LANCASTER (661) 945-2771 • ENCINO (818) 783-4870 • PALMDALE (661) 273-1750 • VICTORVILLE (661) 273-1750
RIDGECREST (760) 446-2233 • TEHACHAPI (661) 823-1845 • VALENCIA (661) 799-0775 • AGOURA HILLS (661) 727-5518