New Patient Request Form - Wait List
Interested in Becoming a New Patient?
"Please complete this form if you would like to be added to a new patient wait list.
We review new patient submissions monthly to fill a limited number of available openings. Our practice primarily serves patients with state-funded insurance plans, including Medicaid. We also accept new patients with private commercial dental insurance on a limited basis.
Please be patient as we work through submissions. Submitting this form does not guarantee acceptance as a new patient or an appointment.
All fields are required so we have the information needed to create your patient account.
Phone inquiries about becoming a new patient will be directed to this form. If a disability or physical limitation prevents you from completing the form online, please call our office for assistance.
Thank you for your patience and interest in our practice!
Please complete one form per patient.
All fields are required unless marked optional.
All information submitted through this form is securely collected and handled in accordance with HIPAA privacy and security requirements.