Simply fill out the form below to request your appointment for your preferred date, and one of our staff will be contacting you to confirm the availability.
Name
*
Phone Number
*
Email address
*
Are you currently a patient at Hillcrest Dental?
*
Please select
Yes
No
First Choice Date
*
MM
/
DD
/
YYYY
I'd like to (select all that apply.)
*
Schedule a New Patient Appointment
Emergency Dental Treatment Appointment
Other Inquiries
First Choice Time
*
Do you have a dental insurance?
*
Please select
Yes
No
If yes, what is your insurance company name?
Insurance ID#
Insurance Group #
Reason for your visit
*
How did you find us?
*
Please select
Google, Yahoo!, Bing, etc.
Yelp
Magazine Ad
Driving By
Direct Mailer
Referral
Other
Submit