Schedule an Appointment

If this is an emergency, you may also call our office at 707-443-7043 to ensure your message is received as soon as possible.

Please give us as much information as you can about your condition. You can be assured that no information from this form is ever released, sold or otherwise misused.

New Patient  Current Patient Former Patient
       
  Emergency    
     
First Name (required)
   
Last Name (required)
   
  Adult
Child
 Age of Child
   
Purpose of Appointment (required)
   
If Toothache: 
Where
How Long - Off/On
How Long - Constant
  Awake at Night Swelling
  Broken Tooth                 
Lost Filling 
Fever      Mobility 
Pain on Pressure Bleeding Gums
 
Sensitive to:
Hot        Cold        Sweets

   
Other
   
If Taking Pain Medication, Specify
   
Referred By
   
Best Way to Contact You (required)
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