Please tell us about your appointment preferences and a member of our staff will contact you with scheduling options or appointment confirmation.
Patient's first and last name (required)
Birthdate (required for positive identification)
Your Email (required)
Primary Phone Number
What is the purpose of the appointment?
Cleaning and examinationFirst VisitEmergency (ex. tooth ache)Cosmetic ProcedureSecond Opinion
How soon would you like to come in?
---Whenever you have time availableAs soon as possibleNext weekTwo weeks from nowNext month
If you would like us to make an appointment for other family members, please list their names here.
Is there any additional information you feel we should know?
Please type the characters you see below:
263 Route 108
Somersworth, NH 03878
Fax: (603) 692-5850