Introducing MEMBERSHIP PLANS

Make An Appointment

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This is a general form. Patients: You may register through the patient portal for secure communication. Doctors referral: Print and fax REFERRAL FORM for secure communication. Fax number: 407 636 6019

Type of appoinement *

• OFFICE VISIT NEW PATIENT
• OFFICE VISIT ESTABLISHED PATIENT
• TELEMEDICINE NEW PATIENT
• TELEMEDICINE ESTABLISHED PATIENT

Phone number *

Email *

Reason appointment for *EmergencyDental appointmentSenior Dental careSore in mouthSleep apneaOral cancer evaluationOral care for cancer patientTMJ/ jaw painDental painGum diseaseFacial pain/ Trigeminal painBurning mouthSpecial care dental needs due to medical conditionUnknown/ rare oral problem

Preferred time

• Morning 8- 11.30AM
• Afternoon 1.00 -4.00 PM

Preferred day

• Monday
• Tuesday
• Wednesday
• Thursday
• Friday
• Saturday 9 AM- 12 noon

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