Appointment Request | La Habra, CA

*Items in bold are required.

Name: Email: Phone:

Are you a current patient?

Yes

Preferred day(s) of the week for an appointment?

Any DayMondayTuesdayWednesdayThursday

Preferred time(s) for an appointment?

Any TimeMorningNoonAfternoonEvening

Please describe the nature of your appointment (e.g., consultation, check-up, etc.):

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.
*We request at least a 48 hour prior notice if you cannot keep an appointment, and we reserve the right to charge a $50 missed HYGIENE appointment fee, and a $100 missed DOCTOR appointment fee.*

Testimonials