Request an Appointment

Parent or Guardian Name:

Patient Name

Patient Date of Birth

Street Address:

Apt #:

City:

State:

Zip/Postal Code:

Email:

Primary Phone Number:

Work Phone Number:

Preferred Appointment Date:

Preferred Time of Day:

If date is not available, 2nd preferred week day:

Reason for Appointment:

If you selected other, please provide an explanation of appointment request:

If you have dental insurance, please list that here (ie. who is your dental insurance carrier?)

Was your child referred by another dentist? If so, who?

Comments:

1133 College Ave STE D 164
Manhattan, KS 66502
Phone: (785) 776-7242
Fax: (785) 776-7243

*Mon – Thur: 8AM – 4:30PM
*Fri: 8AM – 2:30PM
(Closed daily from 12PM – 12:30PM
Sat & Sun: Closed
*Open every other Monday & Friday