The Children's Clinic | Request An Appointment

To request an appoinment for the DENTAL PROGRAM,
please complete the following form we will contact you as quickly as possible.

Appointment Information
My dental clinic is in...
I would like to...	Make an appointment Change an appointment
If you are changing an appointment, what was your scheulded appointment time/date?

Patient Information
Patient's First Name
Patients Last Name
Patient's Date of Birth
Reason for the Visit:
Insurance Provider
Insurance Expiration

Contact Information
Preferred appointment day of the week?
Preferred Appointment Time
How can we reach you best by phone?	() -
Best time to call?	Morning Afternoon Evening
OK to leave a message?	Yes No
Email Address
Additional Comments

Please note that when requesting an appointment, this form does not guarantee an appointment time.

A member of our staff will contact you by phone for
appointment conformation.

If you require immediate or further assistance please contact us directly by calling:

Watertown
(315)788.9834

Lowville
(315)376.4500

Ogdensburg
(315)393.0447



	238 Arsenal St. Watertown, NY 13601 P. (315)782-9450 F. (315)782-2643


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