Appointment Request Form

Contact Information

Your Name (required)

Your Email Address (required)

Address Line 1 (required)

Address Line 2

City (required)

State (required)

Zip Code (required)

Your Phone Number (required)

Alternate Phone Number

Are you a new patient? (required)

Were you referred to our practice by a current patient?

Patient Information

Patient's Name (required)

Appointment Preferences

Which day(s) of the week are you available? (required)
No PreferenceMondayTuesdayWednesdayThursday

Which time(s) of the day are you available? (required)
No PreferenceMorningAfternoonEvening

Please describe the nature of your appointment: (required)

Young couple doing their finances at home

Great Experience!

"This has been the best dental office I have ever been to. Both the office staff and Dr. Coates are so friendly, and very informative on how to keep my mouth and teeth clean."

- Amanda H.

Great, friendly staff.

"Always a good experience! That's saying something for dental work. Staff is very competent and pleasant. I'd recommend them to anyone."

- Leanne B.

Got me right in!

"I was having problems with a tooth, and they got me in right away. Dr. Coates and his staff are always very professional and caring."

- Cheryl B.